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■'•-/<-!
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Cooper Medical Colleire
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LANE MEDICAL LIBRARY
STANFORD UNIVERSITY
MEDICAL CENTER
STANfdRD, CALIF. 94305 ;
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COOPER MEDICAL o.. . ,
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C 8HSBMAH, PRIHTIR,
19 St. James 8tre«t.
TO
P. M. LATHAM, M.D.,
Ain>
GEORGE BURROWS, M.D.,
WHOSE SKILL HAS BEEN PERMITTED T^7ICE TO SAVE MY LIPB,
WHOSE FRIENDSHIP ADDS LARGELY TO MY HAPPINESS,
AND TO WHOSE TEACHING
I SHALL ATTRIBUTE MUCH OF WHATEVER GOOD MY WORK MAT DO,
I DEDICATE THIS VOLUME,
WITH GRATITUDE, AFFECTION, AND RESPECT.
^ ...
Vot;.
It
LECTURES
031
SUEGICAL PATHOLOGY.
TITLES OF THE LECTURES.
1. Nutrition: its Nature, Purpose, and Conditions, .
2. The Conditions Necessary to Healthy Nutrition,
3. The Formative Process : Growth,
4. Hypertrophy, ......
5. Atrophy: Degeneration, ....
6. Atrophy, .......
7. General Considerations on Repair and Reproduction,
8. The Materials for the Repair of Injuries,
9. The Process of the Repair of Wounds,
10. The Same: Continued, . . . . .
11. The Repair of Fractures, ....
12. The Repair of Injuries in Various Tissues,
13. Phenomena of Inflambiation,
14. Products of Inflammation,
15. Developments of Lymph,
16. Degenerations of Lymph,
17. Changes produced by Inflammation
Jl ART, ....
18. Nature and Causes of Inflammation,
19. Mortification,
20. Specific Diseases,
21. Classification of Tumors,
22. Simple or Barren Cysts,
23. Compound or Proliferous Cysts,
24. Fatty and Fibro-Cellular Tumors:
NEOUs Tumors,
25. Fibrous Tumors, ....
26. Recurring Fibroid and Fibro-Nucleated Tumors,
IN the Affected
Painful Subcuta-
PAQB
17
31
49
61
72
84
106
118
131
143
160
174
192
210
227
241
257
275
290
303
318
333
352
374
396
412
XIV
LIST OF ILLUSTRATIONS.
no.
41. Abscess in a tibia, *.....
42. Atrophy of the head and neck of a femur,
43. Diagram of an abscess, .....
44. Development of cysts in the kidney : from Rokitansky,
45. Ovary, with many cysts, .....
46. Proliferous ovarian cyst, ....
47. Minutely proliferous ovarian cyst, ....
48. Cystic disease of the chorion, ....
49. Mammary cyst, with endogenous growth,
50. A similar cyst, with pedunculated growths, .
51. Similar cysts, clustered and filled,
52. Microscopic structures of a fibro-cellular tumor,
53. Section of a fibro-cellular tumor, ....
54. Diagram sections of a uterine outgrowth and a uterine tumor,
54 A. Minute structure of a uterine fibrous tumor,
55. Calcareous deposit in a fibrous tumor : from Dusseau,
56. Section of a fibrous tumor from the hip, .
57. Sections of fibrous tumors on and within the lower jaw,
58. Tissue of a malignant fibrous tumor,
59. Microscopic structures of a recurring fibroid tumor,
60. The same : from another specimen,
61. Microscopic structure of a fibro-nucleated tumor,
62 to 65. Microscopic structures of cartilaginous tumors,
66 to 68. The same, ....
69. Cartilaginous and medullary tumor,
70. Microscopic structure of a soft cartilaginous tumor,
71. Cartilaginous tumor of the humerus,
72. Cartilaginous tumors of the hand,
73. Minute structures of mixed cartilaginous tumors, .
74. Minute structures of myeloid tumors,
75. Myeloid tumor of the skull,
76. Minute structures of the same,
77. Osseous tumor of the face and skull,
78. Minute structures of mammary glandular tumors,
79. The same, of labial tumors,
80. Erectile tumor, ....
81. Bloodvessels of an erectile tumor,
82. 83. Scirrhous cancers of the mammary gland,
84. Scirrhous cancer-cells among the tissues of the skin,
85. Cancer-cells and free nuclei, .
86. Withered cancer-structures,
87. Degenerate cancer-structures, .
88. Scirrhous cancer in a humerus,
89. Scirrhous cancer of the rectum,
90 to 95. Minute structure of medullary cancers,
96, 97. Development of cancer-stroma : from Rokitansky,
98. Epithelial soot-cancer of the hand,
99. Narrow-based epithelial cancer,
100. Deep-seated epithelial cancer of the tongue.
PAOl
. 262'
262
. 264
337
. 352
354
. 355
356
. 359
359
. 360
383
. 384
397
. 400
402
. 406
406
. 411
412
. 416
420
423-24
425
429
432
434
438
. 441
449
452
453
460
470
475
478
481
491
496
496
. 498
498
. 508
509
538-40
543
. 567
568
. 574
LIST OP ILLUSTRATIONS. XV
m. PAoi
101 to 104. Minute strnctiues of epithelial cancers, .... 578-81
105. Diagram of the fonnation of laminated capsules: from Rokitansky, 582
lOG. Melanoid cancer, ........ C07
107. Minute structures of the same, ....... 007
108. Osteoid cancer of the femur, ....... 014
109. Osteoid cancer of a lymphatic gland, .015
110. Fibrous tissue of an osteoid cancer, . . OIG
HI. Villous cancer of the bladder, . .021
112. Dendritic vegetation: from Rokitansky, ..... 022
113. Fibrous tissue of a colloid cancer, ...... 027
114. Minute structures of colloid cancer: from Lebert and Rokitansky, . 028
115-16. Minute structure of pulmonary tubercle: fVom Schroeder van der Kolk, 071-72
LECTURES
OH
SURGICAL PATHOLOGY.
LECTURE I.
NUTRITION — ^ITS NATURE, PURPOSE, AND CONDITIONS.
Mr. President and Gentlemen. — ^I believe that I owe the honor
of being elected Professor of Anatomy and Surgery to the College,
chiefly to my having been long engaged in the study of the pathological
department of the Museum, while arranging and describing it, under the
superintendence of Mr. Stanley, for the new catalogue. I may, there-
fore, fairly suppose it to be the wish of the Council that, as the Museum
is open to the examination of the members and pupils of the College, and
of men of scientific pursuit, so should be the knowledge and conditions
which it has supplied or suggested to those who have had occasion to
study it most deeply. For, indeed, to what thus grows out of the study
of the Museum, the College has, in some measure, the right which the
proprietor has to the produce of the cultivated soil. And when, through
a long time past, your most learned Hunterian Professor Owen has every
year brought in, from every source, so large a store of deep and wide-
extending knowledge, of sagacious interpretation, and acute suggestion
of the ways of Nature, I scarcely wonder that some return should be
looked for from an inferior laborer in the field.
The subjects on which I shall first beg your favorable hearing are
those to the general illustration of which the first two series of prepara-
tions in the Pathological Museum are devoted — namely, hypertrophy and
atrophy; the simple excess, and the simple deficiency, of nutrition in
parts. But let me previously speak of the healthy nutrition of the tis-
sues, and, herein especially, of the formative process which maintains
them by assimilation. ^
In the natural course of life, the formative process manifests itself in
three modes, which, though they bear different names, and are sometimes
2
18 NUTRITION,
described as if they were wholly different things, yet, probably, are only
three expressions of one law, three effects of the same force operating in
different conditions. The three, enumerating them in the order of their
time, are development, growth, and assimilation or maintenance.
By development, we mean, generally, the process by which a tissue or
organ is first formed ; or by which one, as yet imperfectly formed, is so
changed in shape or composition as to be fitted for a higher function, or,
finally, is advanced to the state in which it exists in the most perfect con-
dition of the species.
We must carefully distinguish development from mere increase : it is
the acquiring, not of greater bulk, but of new forms and structures, which
are adapted to higher conditions of existence. For example, when, in
the embryo, groups of nucleated cells are changed into bundles of mus-
cular fibrils, there is not, necessarily, an increase of size ; or, if there be,
there is something more ; there is a change of texture, and an acquire-
ment of power adapted to a higher state of existence : these constitute
development. So, when, from the simple cavity and walls of the embry-
onic digestive system, the stomach, intestines, liver, pancreas, and other
organs are produced, these are developed ; there is increase, but, at the
same time, something more than mere increase.
The distinction between development and increase, or growth, is well
shown in this, — that, sometimes, even in instances in which they usually
concur, the one proceeds without the other. I might quote many
examples of this. I will choose two or three, which at the same time,
may illustrate some other striking facts. Among the malformations in
the Museum of St. Bartholomew's Hospital (Series A, 121 and 123),
are the brains of two adult idiots. They are equally diminutive, and of
nearly equal size : but in one, so far as we can see, there is a due propor-
tion of the several parts ; it is only too small : in the other, the parts are
not well proportioned ; the posterior parts of the cerebrum do not half
cover the cerebellum ; indeed, no posterior cerebral lobes appear to be
formed. Herein we recognise something more than a checked growth ;
for this truncation of the cerebrum indicates an arrest of its development
at the time when its hinder lobes — ^the parts last produced, and pecu-
liarly characteristic of the human brain — ^were only just beginning to be
formed. Our explanation of this most interesting specimen must be,
that, when the brain had attained that degree of development which,
according to Professor Betzius,'*' is proper to the human foetus about the
beginning of the fifth month, and corresponds with the completed de-
velopment of the brain of lower mammalia, then its development ceased.
But though in form it is like the foetal brain in the fifth month, yet, in
all its dimensions, it is larger ; so that, although its development had
ceased, its growth contin#d, and was not checked till the brain had
• Arch. d'Anat. et de Physiol., Jan. 184G.
J
ITS NATURE, PURPOSE, AND CONDITIONS. 19
attained the size of that of a matnre foetus. In this brain, therefore, we
find at once defectiye deyelopment and defective growth; but in the
other the development proceeded, and the growth alone was checked.
Again, for examples in which development was checked and growth
proceeded even beyond its normal limits, we may examine some of the
numerous malformed hearts in the Museum. One among them presents
only a single cavity ; no partition has been developed between its auridee
or its ventricles ; it is, in respect of its development, like the heart of a
foetus in the second month : but though its development was checked
thus early, its growth continued, and it has more than the average size
of the hearts of children of the same age. In another, development was
arrested at a later period, when the septum of the ventricles was incom-
pletely formed ; the patient lived eleven years after birth ; the develop-
ment made no further progress, but the growth passed its ordinary
bounds.
And, once more, for instances in which the development was normal
and growth abnormal, you may examine such skeleton^ as those of
O'Byme the giant, and of Madlle. Cracami the dwarf, in the Physiolo-
gical Museum. The one is eight feet high, the other is only twenty
inches : but if you compare these with the model skeletons which stand
beside them, you will not find in the one a defect, nor in the other an
excess, of development ; the dwarf has not less than all the characteristic
human forms, the giant has no more ; but the one is defective, the other
is excessive, in its bulk ; the growth alone has been erroneous in both.
It is, then, in the change to a higher state of form or composition,
that development differs from growth, the second mode of the formative
process. In mere growth, no change of form or composition occurs ;
parts only increase in weight, and usually, in size. In growth, there
is an addition of quantity, but no improvement in the quality, of a part ;
the power of the growing part increases with the growth, but is only
more of the same power ; so, in the attainment of manhood, the heart of
the boy, having all its necessary parts, and all well-formed, acquires per-
fection by acquiring greater bulk, and, therewith, greater power.
Lastly, in the formative process, as it is normally manifested in the
adult, I. e., in ordinary assimilation or maintenance, parts only preserve
their status. No perceptible change of size or weight ensues, no change
of form or composition ; sameness is maintained through the regular for-
mation of new parts in the place of those which, in the ordinary course
of life, are impaired, or die.
Such are the methods of the formative process in the nutrition of
organs. I shall have to show in future lectures, that some of the terms
just used are, in a measure, conventional and arbitrary; that some
instances of what we call development, e.^., ftat of cartilage into bone,
are not in every sense justly so named ; and that the sameness, which is
maintained in the adult body, fades into a gradual degeneration. But,
20 NUTRITION,
for the present, the terms that I have used may suffice. It is conyenient,
also, to think of the three methods of formation, as if each might be
separately manifested ; yet, probably, they are always concurrent ; the
maintenance of whole organs being achieved only by the constant deve-
lopment and growth of new elemental structures in the place of those
that are outworn.
Now, for the elucidation of this maintenance of parts by the constant
mutation of their elemental structures, let me speak —
1st. Of the sources of impairment, or, if I may so say, of the wear
and tear, to which every part of the body appears to be subject.
2dly. Of the conditions necessary for the healthy state of the process
of nutrition by which the results of the wear and tear are repaired.
3dly. Of the formative process itself.
First, then, the deterioration of the body may be traced to two prin-
cipal sources ; namely, the wearing-out of parts by exercise, and the
natural deterioration or death of the elemental structures of every part
or organ, independent of the decay or death of the whole body, after a
certain period of eidstence.
From the first of these, the wearing-out of parts by exercise, it is pro-
bable that no tissue or part enjoys immunity. For although, in all the
passive apparatus of the body — ^the joints, bones, ligaments, elastic ves-
sels, and the like — ^much of the beauty of their construction consists in
the means applied to diminish the effects of the friction, and the various
pressures and stretchings to which they are* subject, yet, in enduring
these at all, they must be impaired, and, in the course of years, must
need renewal. Doubtless, however, the waste of these parts by exercise
is much less than that of the more active organs, such as the muscles,
and, perhaps, the nervous system. With regard to the muscles, it is
clear that chemical decomposition and consumption of their substance
attend their continued action. Such action is always followed by the
increased discharge of urea, carbonic acid, and water. The researches
of Helmholtz* show, that the muscles themselves, after long repeated
contractions, are changed in chemical composition; and those of Gt.
Liebig,t have detected and measured the formation of carbonic acid in
them during similar contractions.
We have nearly similar evidence of the impairment of the nervous
system by prolonged exertion of its power. We have, indeed, no proof
that the simple conduction of an impression through a nervous cord can
affect in any way its composition or its structure ; but the abundance of
phosphates occasionally discharged with the urine, after great mental
exertion, shows that the various acts of the mind impair the brain through
which they are manifested. To this point tend, also, the researches of
• Mailer's Archiv. 1845, p. 72.
t Ibid. 18G0, p. 393.
ITS NATURE, PURPOSE, AND CONDITIONS. 21
Dr. Bence Jones,* who has shown that the excretion by the kidneys of a
large quantity of phosphate salts is usual in acute inflammation of the
brain. And to this conclusion, that mental exercise, whether perceptive
or active, impairs the structure of the brain, we might be led by our
sensations and by our knowledge of the nature of the Mind. For to the
principle, the immaterial thing, we cannot ascribe a weariness; it cannot
be obnoxious to waste or to decay : mental fatigue is only what the Mind
feels of an impaired state of the brain, and the recovery from what we
call a weary mind is the restoration, not of the Mind itself, but of the
organs which it feels, which connect it with the external world, and in
which, during tranquil sleep, the reparative nutrition goes on undis-
turbed.
It is further probable that no part of the body is exempt from the
second source of impairment ; that, namely, which consists in the natural
death or deterioration of the parts (independent of the death or decay of
the whole body) after a certain period of their life. It may be proved,
partly by demonstration, and partly by analogy, that each integral or
elemental part of the body is formed for a certain natural period of ex-
istence in the ordinary condition of active life, at the end of which
period, if not previously destroyed by outward force or exercise, it de-
generates and is absorbed, or dies and is cast out ; needing, in either
case, to be replaced for the maintenance of health, f
The simplest examples that I can adduce of this are in the hair and
teeth ; and in the process which I shall describe, and illustrate with a
diagram (on p. 22), we seem to have an image in which are plainly marked,
though, as it were, in rough outline, all the great features of the process
by which tissues are maintained.
An eyelash which naturally falls, or which can be drawn out without
pain, is one that has lived its natural time, and has died, and been sepa-
rated from the living parts. In its bulb such an one will be found very
different from those that are still living in any period of their age. In
the early period of the growth of a dark eyelash, we find its outer end
almost uniformly dark, marked only with darker short linear streaks,
and exhibiting no distinction of cortical and medullary substance. Not
far from its end, however, this distinction is plainly marked ; dark as
the cortical part may be, the medullary appears like an interior cylinder
of much darker granular substance : and in a young hair this condition
is continued down to its deepest part, where it enlarges to form the bulb.
(Fig. 1. A.) Now this enlargement, which is of nearly cup-like form,
appears to depend on the accimiulation of round and plump nucleated
• Med. Chir. Trans., Vol. xxx., p. 20.
t Hunier (Works, vol. iii., p. 495), and Treviranus (Biologie, B. iii. p. 482), maybe thought
to have had some insight into this important law ; but the merit of having first maintained
in terms nearly similar to the above, and as more than an hypothesis, that " each part of the
organism has an individual life of its own," and " a limited period of existence,'' belongs to
Dr. Carpenter. — Principles of Human Physiology, 3d edit, p. 623.
NKTRITIOS,
cells, whicli, according to their position, are either, bj nan'oviog and
elongation, to form the dry fibro-celb of the outer part of the growing
and fnrther protruding sha^, or are to be transformed into the air-holding
oellB of the medullary portion. At thia time of moat active growth, both
cells and snclei contain abundant pigment-matter, and the whole bulb
looks nearly black. The sources of the material out of which the cells
form themselves are,. at least, two; namely, the inner surface of the
sheath or capsule, which dips into the skin, enveloping the hair, and the
surface of the vascular pulp, which fits in a conical cavity in the bottom
of the hair-bulb.
Such is the state of parts so long as the growing hair is all dark.
But, [M it approaches the end of its existence, it seems to give tokens of
advancing age, by becoming gray. (Fig. 1. B, c.) Instead of the almost
sudden enlargement at its bulb, the hair only swells a little, and then
tapers nearly to a point ; the conical cavity in its base is contracted, and
hardly demonstrable, and the cells produced on the inner surface of the
capsule contain no particle of pigment. Still for some time it continues
thus to live, and grow, and we find that the vigor of the conical pulp
lasts rather longer than that of the sheath or capsule ; for it coatinues
to produce pigment matter some time after the cortical substance of the
hair has been entirely white, and it is still distinct, because of the pig-
ment-cells covering its surface.
At length the pulp can be no longer discerned, and uncolored cells
alone are produced, and maintain the latest growth of the hair. With
these it appears to grow yet some further distance, for we see traces of
ITS NATURE, PURPOSE, AND CONDITIONS. 28
their elongation into fibres or fibro-cells, in lines rmining from the inner
surface of the capsule inwards and along the surface of the hair ; and we
can always observe that the dark column of medullary air-containing sub-
stance ceases at some distance aboye the lower end of the contracted
hair-bulb, (c, D.)
The end of all is the complete closure of the conical cavity in which
the hair-pulp was lodged ; the cessation of the production of new cells ;
and the consequent detachment of the hair as a dead part, which now
falls by the first accident ; falls, sometimes, quite bare and smooth on
the whole surface of its white bulb, but sometimes bringing with it a
layer of cells detached from the inner surface of the capsule, (d.)
Such is the life of a hair, and such its death ; which death, you see, is
natural, spontaneous, independent of exercise, or of any mechanical ex-
ternal force, the natural termination of a certain period of life. Yet,
before it dies, provision is made for its successor ; for when its growth is
failing, you often find, just below the base of the old hair, a dark spot,
the germ or young pulp of the new one ; it is covered with cells contain-
ing pigment, and often connected by a series of pigment-cells with the
old pulp or capsule. (Fig. 1, c.) And this appears to be the product,
as it were an ofifshoot, from some portion of the capsule of the old hair ;
for though it may sometimes appear only in the form of a conical pulp,
yet more often, I think, it shows signs of connexion with the capsule,
and the cone is only more evident than the rest because of its covering
of dark cells.*
I believe that we may assume an intimate analogy between the process
of successive life and death, and life communicated to a successor, which
is here shown, and that which is believed to maintain the ordinary nu-
trition of a part. It may be objected, indeed, that the death and casting
out of the hair cannot be imitated in internal parts ; but we are not with-
out an example in which the absorption of a worn out internal particle is
exactly imitated in larger organs, at the end of their appointed period of
life. I adduce the instance of the deciduous or milk-teeth.
We trace each of these developed from its germ, and in the course of
its own development, separating a portion of its capsule for the germ of
its successor : then each, having gained its due perfection, retains for a
time its perfect state, and still lives, though it does not grow. But at
length, as the new tooth comes, the deciduous tooth dies, coincidently,
not consequently ; or rather, the crown of the old tooth dies, and is cast
out like a dead hair ; while its fang, with the bony sheathing, and the
* Tliis account of the cliange of the hair is confirmed by the much more minute de-
scnption of Kolliker (Mikrosk. Anatomie, B. ii., p. 141). His observations were made
chiefly in the young child, mine in the adult ; but, doubtless, his account of the complete
continuity of the sheath of the new hair with that of the old one, of the gradual extrusion
of the old hair, and of roost of the details of the process, might be added to what I have
detcribed.
24 NUTRITION,
yascular and nervous pulp, degenerate, and are absorbed. It is here
especially to be observed, that the degeneration is accompanied by some
spontaneous transformation of the fang ; for it could not be absorbed
unless it were first so changed as to be soluble. And it is degeneration,
not death, which precedes its removal ; for when a tooth-fang really dies
as that of the second tooth does in old age, then it is not absorbed, but
is cast out entire, as a dead part.
Such, or nearly such, it seems almost certain, is the process of nutri-
tion everywhere : these may be taken as types of what occurs in other
parts ; for these are parts of complex organic structure and composition,
and the teeth-pulps, which are absorbed as well as the fangs, are very
vascular |and sensitive, and therefore, we may be nearly sure, are con-
formed to only the same laws as prevail in all equally organized parts.
Nor are these the only instances that might be adduced. We see the
like development, persistence for a time in the perfect state, death, and
discharge, in all the varieties of cuticles, with which, also, we may con-
nect the example of the gland cells ; and in the epidermis we have, as
in the teeth, an evidence of chemical change in the old cells, in the very
different influence which acetic acid and potash exercise on them and on
the younger cells, making these transparent, but leaving them scarcely
changed.
These things, then, seem to show that the ordinary course of each ele-
mentary organ in the body, after the attainment of its perfect state by
development and growth, is, to remain in that state for a time ; then,
independently of the death or decay of the whole body, and, at least in
a great measure, independently of its own exercise or exposure to exter-
nal violence, to die or to degenerate ; and then, being cast out or ab-
sorbed, to make way for its successor.
It appears moreover very probable, that the length of life which each
part is to enjoy is fixed and determinate, though of course in some de-
gree, subject to accidents, which may shorten it, as sickness may prevent
death through mere old age ; and subject to the expenditure of life in
the exercise of function. I do not mean that we can assign, as it is
popularly supposed we can, the time that all our parts will last; nor is
it likely that all parts are made to last an equal time, and then to be
changed. The bones, for instance, when once completely formed, must
last longer than the muscles and other softer tissues. But, when we see
that the life of certain parts is of determined length, whether they be
used or not, we may assume, from analogy, the same of nearly all.
For instance, the deciduous human teeth have an appointed duration
of life : not, indeed, exactly the same in all persons, yet, on the whole,
fixed and determinate. So have the deciduous teeth of other animals.
And, in all those niunerous instances of periodical moulting, of shedding
of the antlers, of the entire desquamation of serpents, and of the change
damage in birds, and of the hair in mammalia ; what means all this,
^<^.
ITS NATURE, PURPOSE, AND CONDITIONS. 25
but that these organs live their severally appointed times, degenerate,
die, are cast away, and in due time are replaced by others ; which, in
their turn, are to be developed to perfection, to live their life in the ma-
ture state, and to be cast off? We may discern the same laws of life in
some elementary structures; for example, in the blood-corpuscles, of
which a first set, formed from embryo-cells, disappear at a certain period
in the life of the embryo, being replaced and superseded by a second set
formed from lymph-corpuscles. And in these, also, we may see an ex-
ample of the length of life of elemental parts being determined, in some
measure, by their activity in function ; for if the development of the tad-
pole be retarded, by keeping it in a cold, dark place, and if, in this con-
dition, the functioft of the first set of blood-corpuscles be slowly and im-
perfectly discharged, they will remain unchanged for even many weeks
longer than usual : their individual life will be thus prolonged, and the
development of the corpuscles of the second set will be, for the same time
postponed.*
The force of these facts is increased by the consideration of the exact
analogy, the almost identity, of the processes of secretion and nutrition ;
for in no instance is the fact of this limited life of individual parts more
clearly shown than in the gland-cells, by which periodical secretions are
elaborated. The connecting link between such gland-cells and the most
highly organized parts, as well as a manifest instance of determinate
length of life and natural death, is found in the history of the ova.
These attain their maturity in fixed successive periods of days : they are
separated (as the materials of several secretions are) while yet living, and
with a marvellous capacity of development, if only they be impregnated
during the few days of life that remain to them after separation ; but, if
these days pass, and impregnation is not effected, they die, and are cast
out, as impotent as the merest epithelial cell.
Now from these cases it is not by a far-fetched analogy that we assume
the like mortality in all other tissues ; and that this is the principal
source of impairment, and of change for the worse, which every part of
the body has within itself, even in the most perfect state, and in the con-
ditions most favorable to life. And I may anticipate a future subject of
consideration, by saying that the application of these truths is of some
importance in practical pathology ; inasmuch as the results of this de-
generation of parts, at the close of their natural term of life, may be
mingled with the effects of all the morbid processes by which the natural
nutrition of a part is hindered or perverted. Hence, at least in part, the
long-continuing or permanent loss of power in an organ (say a muscle)
which has been disused, or has been the seat of inflammation. This loss
is not wholly due to a primary disease of the fibre ; in part, it is because
the inflammatory process and the organization of the morbid exudation
exclude the ordinary process of nutrition ; and the muscular fibres, which
• See Kirke3*s Physiology, pp. 05 and 290.
26 NUTRITION,
now, in the ordinary course of life, degenerate, are not replaced, or are
imperfectly repaired.
Of the results of these natural and unrepaired degenerations of tissues
I shall speak more hereafter. Let me now consider the conditions under
which the repair of parts thus deteriorated is eflFected ; for it is against
the effects of these natural deteriorations that the process of nutrition in
the adult is chiefly directed ; and it appears to he hy the disturbance or
removal of certain necessary conditions, more often than by any suspen-
sion or perversion of itself, that error is engendered in the process of
formation. And, in speaking of these conditions of healthy nutrition, I
shall take leave occasionally to diverge, even very far, into the conside-
ration of certain points of interest in the general physiology of the
process.
Doubtless the conditions necessary to the normal nutrition of parts are
very many : but the chief of them are these four : —
1. A right state and composition of the blood or other nutritive
material.
2. A regular and not far distant supply of such blood.
8. (At least in most cases) a certain influence of the nervous system.
4. A natural state of the part to be maintained.
And, first, of the right state of the blood, I may observe that I use the
expression "right state" rather than "purity," because, if the latter be
used, it seems to imply that there is some standard of composition to
which all blood might be referred, and the attainment of which is essen-
tial to health ; whereas the truth seems rather to be, that, from birth
onwards, the blood and tissues of each creature are adapted to one an-
other, and to the necessary external circumstances of life, and that the
maintenance of health depends on the maintenance and continual re-
adjustment of the peculiarities on which this exact adaptation depends.
The necessity for this right or appropriate state of the blood, as a
condition of healthy nutrition, involves of course the necessity for the
due performance of the blood-making and blood-purifying functions ; it
requires healthy digestion, healthy respiration, healthy excretion. Any
one of these being disturbed, the formative process in a part or in the
whole body may be faulty, for want of the appropriate material. But,
important as these are, we must not let the consideration of them lead
us to forget that there is something in the blood itself, which is at least
as essential to the continuance of its right and healthy state as these are,
and which is, indeed, often occupied in correcting the errors to which
these, more than itself, are subject ; I mean the power of assimilation or
maintenance which the blood possesses, in and for itself, as perfectly
and at least as independently as any of the tissues. By this it is, that
notwithstanding the diversity of materials put into the blood, and the
diversity of conditions in which the functions ministering to its forma-
tion are discharged, yet the blood throughout life retains, in each person,
certain characters as peculiar as those of his outer features for the con-
ITS NATURE, PURPOSE, AND CONDITIONS. 27
tinual renewal of which it provides appropriate materials. And by this
assimilative power of the blood it is that the tissues are continually
guarded ; for by it many noxious substances introduced into the blood
are changed and made harmless before they come to the tissues ; nor
can any substance, introduced from without, produce disease in an organ,
nnless it be such an one as can escape the assimilative and excretory
power of the blood itself.
In this maintenance is the chief manifestation of the life of the adult-
blood ; a life, in all essential things, parallel and concurrent with that
of the tissues. For in the blood we may trace all those which we recog-
nise as signs and parts of life in the solids : we watch its development,
its growth, its maintenance by the assimilation of things unlike itself;
we find it constituting an adapted purposive part of the organism ; pos-
sessing organic structures ; capable of disease and of recovery ; prone
to degeneration and to death. In all these things, we have to study the
life of the blood as we do that of the solid tissues ; the life, not only of
the structures of the blood, but of its liquid also ; and as, in first de-
velopment, the blood and tissues are made, of similar materials, in exact
conformity with one another, so, through later life, the normal changes
of each concur to maintain a like conformity and mutual adaptation. I
cannot now dwell on these points ;* but they will be frequently illustrated
in the following lectures, and some of them at once, in what I have to
say of the precision of adjustment in which the " right state" of the
blood consists.
Notwithstanding its possession of the capacity of maintenance, the
blood is subject to various diseases, in consequence of which the nutri-
tion of one or more tissues is disordered. The researches of modern
chemistry have detected some of these changes; finding excesses or
deficiencies of some of the chief constituents of the blood, and detecting
in it some of the materials introduced from without. But a far greater
number of the morbid conditions of the bjood consist in changes from
the discovery of which the acutest chemistry seems yet far distant, and
for the illustration and discussion of which we cannot adopt the facts,
though we may adopt the language and the analogies, of chemistry. It
is in such diseases as these that we can best discern how nice is that
refinement of mutual influence, how exact and constant that adaptation,
between the blood and tissues, on which health depends.
I know no instance so well adapted to illustrate this as the examples
of symmetrical diseases. The uniform character of such diseases is,
that a certain morbid change of structure on one side of the body is
repeated in the exactly corresponding part on the other side. In the
lion's pelvis, for example, which is sketched in the annexed diagram
from a specimen, (No. 8080,) in the College Museum, multiform as the
• They formed the subject of the course of Lectures delivered at the College in 1848, an
abetract of part of which is given by Dr. Kirkes in his "Handbook of Physiology,' p. 64,
ad. 8.
COOPER MZDIQAU T-.-.. .
SAN F7M//OrS0O. OAU
KUTRITIOH,
pattern is in wluch the new bone, the product of some disease compa-
rable with a human rheumatiflm, is deposited — a pattern more complex
and irregular than the spots upon a map — there is not one spot or line
on one aide which is not represented, as exactly ts it would he in a mirror,
on the other. The likeness has more than Daguerr^type exactness, and
was observable in numerous pairs of the bones similarly diseased.
I need not describe many examples of such diseases. Any out-patients'
room will furnish abundant instances of exact symmetry in the eniptions
of eczema, lepra, and psoriasis ; in the deformities of chronic rheumatism,
the paralyses from lead ; in the eruptions excited by iodide of potassium
or copaiba. And any large museum will contain examples of equtJ
symmetry in syphilitic ulcerations of the skull ; in rheumatic and syphi-
litic deposits on the tibise and other bones ; in all the effects of chronic
rheumatic arthritis, whether in the bones, the ligaments, or the carti-
lages ; in the fatty and earthy deposits in the coats of arteries.
Now, these facts supply excel-
"**■ __. . lent evidence of the refinement of
f the affinities which are concerned
in the formative process. Ex-
cluding, perhaps, the cases of con-
genital defects that are symmetri-
ca!, and a few which seem to
depend on morbid influence of the
nervous system, it may be stated,
generally, that all symmetrical
diseases depend on some morbid
material in the blood. Tou may
find the proof of this position in
papers written simultaneously by
Dr. William Budd and myself;*
and in Dr. Budd's essay you may
find it nearly demonstrated, by a
masterly discussion of the subject,
that, in most of these cases, the
morbid material enters into combi-
nation with the tissue which is
diseased, or with the organized
product of the morbid process.
Now the evident and applicable
truth in all these cases is, that the
morbid substance in the blood, be
it what it may, acts upon and
changes only certain portions of what we might suppose to be all the
very same tissue. Such a substance fastens on certain islands on the
* Medico-Chirurg. Ttaiu. vol. sxr.
ITS NATUBE, PURPOSE, AND CONDITIONS. 29
surfaces of two bones, or of two parts of the skin, and leaves the rest
unscathed ; and these islands are the exactly corresponding pieces upon
opposite sides of the body. The conclusion is unayoidable, that these
are the only two pieces that are exactly alike ; that there was less affinity
between the morbid material and the osseous tissue, or the skin, or the
cartilage, close by; else, it also would have been similarly diseased.
Manifestly, when two substances display different relations to a third,
their composition cannot be identical ; so that though we may speak of
all bone or of all skin as if it were all alike, yet there are differences of
intimate composition ; and in all the body the only parts which are exactly
like each other, in their mutual relation with the blood, are those which
are symmetrically placed upon the opposite sides. No power of artificial
chemistry can, indeed, detect the difference ; but a morbid material can :
it tests out the parts to which it has the greatest affinity, unites with
these, and passes by the rest."*"
I might magnify the wonder of this truth by showing how exceedingly
small, in some of these cases, must be the quantity of the morbid material
existing in the blood. But I prefer to illustrate a fact which singularly
corroborates the evidence, afforded by symmetrical diseases, of the refine-
ment of the operations of the affinities, if we may so call them, between
the blood and the tissues. The fact is that of certain blood-diseases
having "seats of election." For example, in another lion's pelvis, No.
3024, diseased like that sketched above, not only is the morbid product
just as symmetrical, but its arrangement is exactly similar : hardly a spot
appears on one pelvis which is not imitated on the other. And these
are only examples of a large class of cases of syphilis, rheumatism, and
various skin-diseases, of which the general character is, that the disease
is much more apt to affect one certain portion of a bone, or of the skin,
or of some other tissue, than to attack any other portion. We are all in
the habit of using the fact as an aid in diagnosis ; but we may have over-
looked its bearing on the physiology of nutrition. It proves, on the one
hand, as the cases of symmetrical diseases do, that the composition of
the several portions of what we call the same tissue is not absolutely
identical : if it were, these diseases should affect one part of a bone or
other tissue as often as. another part, or should affect all parts alike.
* Some of the differences here noticed are not permanent, but may seem to depend on the
several parts of a bone, or of the skin, of a limb (for example), being in different stages of
development or degeneration. The symmetrical parts of the tissue, being exactly alike, may
be simultaneously and equally affected by a disease, while other parts of the same remain
unaffected, till, in the course of time, they attain, by development or degeneration, the very
same condition as the parts first affected. Then, if the morbid material still exist in the
blood, these parts also become diseased : and so in succession may nearly the whole of
a tissue. This view agrees very well with the fact Uiat symmetrical diseases oAen spread,
and flo prove that a part which, in one week or month, is not susceptible of the influence of
a morbid material, may, in the next, become as susceptible as that which was first affected.
This Muceptibility, however, may be due not to normal changes, but to the influence which
the diseased portion of the tissue exercises on those around it.
80 NUTRITION, ITS NATURE, PURPOSE, AND CONDITIONS.
And it proves, on the other hand, a constant similarity, even an identity,
of the morbid material on which each of these diseases depends, though
it be produced in different individuals ; so that we ihay venture to predict,
that whenever chemistry shall discover the composition of these materials,
it will be found as constant and as definite as the composition of those
inorganic substances which the science has most successfully scrutinized.
Moreover, Dr. William Budd has proved that, next to the parts which
are symmetrically placed, none are so nearly identical in composition as
those which are homologous. For example, the backs of the hands and
of the feet, or the palms and soles, are often not only symmetrically, but
similarly, affected with psoriasis. So are the elbows and the knees ; and
similar portions of the thighs and the arms may be found affected with
icthyosis. Sometimes, also, specimens of fatty and earthy deposits in
the arteries occur, in which exact similarity is shown in the plan, though
not in the degree, with which the disease affects severally the humeral
aud femoral, the radial and peroneal, the ulnar and posterior tibial,
arteries.
Toe onclude, these symmetrical diseases with seats of election, prove —
Ist. That in the same person the only parts of any tissue which are
identical in composition are, or may be, first, those which occupy sym-
metrical positions on the opposite sides of the body ; and next, those
which are in serial homology.
2dly. That the portions of the bodies of different individuals which are
identical, or most nearly so, in composition, are those in exactly corre-
sponding positions.
Sdly. That even in different individuals the specific morbid materials,
on which many of the diseases of the blood depend, are of identical
composition.
It would be foreign to my purpose to enter now upon all the subjects
of interest which are illustrated by these cases. I may. refer you again
to the papers already mentioned, especially to Dr. Budd's. For the
present it will be suflScient if I have proved (without pretending to explain
or describe) the perfect and most minute exactness of the adaptation
which, in health, exists between the blood and all the tissues ; and that
certain inconceivably slight disturbances of .this adaptation may be
sources of disease. K this be proved, I shall not fear to be met with an
objection against too great refinement in what I shall next say concern-
ing some of the means by which that right state of the blood, which is
appropriate to the healthy nutrition of all the parts, is attained and
preserved.
81
LECTURE 11.
THE CONDITIOKS KECB8SART TO HEALTHY KUTRITION.
I NEED not dwell on the physiology of the processes of digestion,
absorption, excretion, and others, which, on the large scale, serve in the
development and maintenance of the blood. The admitted doctrines
concerning these I most assume to be well known, while I proceed with
the consideration of those minuter relations, in which the blood and the
several tissues exercise their mutual influence, and by which each is
maintained in its right state. And, first, let me endeavor to develope a
principle, the germ of which is in the writings of Treviranus. His sen-
tence is, that ^^ each single part of the body, in respect of its nutrition,
stands to the whole body in the relation of an excreted substance.""^ In
other words, every part of the body, by taking from the blood the pecu-
liar substances which it needs for its own nutrition, does thereby act as
an excretory organ, inasmuch as it removes from the blood that which,
if retained in it, would be injurious to the nutrition of the rest of the
body. ^Thus, he says, the polypiferous zoophytes all excrete large quan-
tities of calcareous and siliceous earths. In those which have no stony
skeleton these earths are absolutely and utterly excreted ; but in those
in which they form the skeleton, they are, though retained within
the body, yet as truly excreted from the nutritive fluid and all the
other parts, as if they had been thrown out and washed away. So
the phosphates which are deposited in our bones are as efiectually ex-
creted from the blood and the other tissues, as those which are discharged
with the urine.
But Treviranus seems not to have apprehended the full importance of
the principle which he thus plearly, though so briefly, stated ; for it ad-
mits, I think, of far extension and very interesting application.
Its influence may be considered in a large class of outgrowing tissues.
The hair, for example, in its constant growth, serves, not only local
purposes, but for the advantage of the whole body, in that, as it grows,
it removes from the blood the various constituents of its substance,
which are thus excreted from the body. And this excretion ofBce ap-
pears, in some instances, to be the only one by which the hair serves the
purpose of the individual ; as, for example, in the foetus. Thus, in the
' * Die Eranheio. nod Getetze det organischen Lebons, B. I, p. 401.
32 CONDITIONS NECESSARY TO
foetus of the seals that take the water as soon as they are bom, and, I
believe in those of many other mammals, though they are removed from
all those conditions against which hair protects, yet a perfect coat of
hair is formed within the uterus, and before, or very shortly after birth,
this is shed, and is replaced by another coat of wholly different color,
the growth of which began within the uterus. Surely, in these cases, it
is only as an excretion, or chiefly as such, that this first growth of hair
serves to the advantage of the individual. The lanugo of the human
foetus is an homologous production, and must, I think, similarly serve in
the economy by removing from the blood, as so much excreted matter,
the materials of which it is composed.
Further, I think, we may Carry this principle to the apprehension of
the true import of the hair which exists, in a kind of rudhnental state,
on the general surface of our bodies, and to that of many other perma-
nently rudimental organs, such as the mammary glands of the male, and
others. For these rudimental organs certainly do not serve, in a lower
degree, the same purposes as are served by the homologous parts which
are completely developed in other species, or in the other sex. To say
they are useless, is contrary to all we know of the absolute perfection
and all-pervading purpose of Creation ; to say they exist merely /or the
sake of conformity with a general type of structure, seems unphilosophi-
cal, while the law of the unity of organic types is, in larger instances,
not observed, except when its observance contributes to the advantage of
the individual. Rather, all these rudimental organs must, as they grow,
be as excretions, serving a definite purpose in the economy by remov-
ing their appropriate materials from the blood, and leaving it fitter for
the nutrition of other parts, or by adjusting the balance which might
else be disturbed by the formation of some other part. Thus they minister
to the self-interest of the individual, while, as if for the sake of wonder,
beauty, and perfect order, they are conformed with the great law of the
unity of organic types, and concur with the universal plan observed in
the construction of organic beings.
And again, — the principle that each organ, while it nourishes itself,
serves the purpose of an excretion, has an application of peculiar interest
in the history of development. For if it be influential when all the
organs are already formed, and are only growing or maintaining them-
selves, much more will it be so when the several organs are successively
forming. At this time, as each nascent organ takes from the nutritive
material its appropriate constituents, it will co-operate with the gradual
self-development of the blood, to induce in it that condition which is
essential, or most favorable, to the formation of the organs next in order
to be developed.
The importance of this principle will the more appear, if we connect
with it another, equally characteristic of the minuteness of the relation
between the blood and the tissues, namely, that the existence of certain
HBALTHT NUTRITION. 88
materials in the blood may determine the formation of structures in Vhich
they may be incorporated.
This seems to be established, as a general law in pathology, by the
cases in which diseased structures evidently incorporate materials that
had their origin or previous existence in the blood. Such are most of
those inocidable and other blood dise&ses in which morbid organisms are
produced ; as vaccinia, variola, chancre, glanders, &c. The same law
may be made very probable in physiology also. For example, when one
kichiey is destroyed, the other often becomes much larger, does double
work, as it is said ; and the patient does not suffer from the retention of
urine in the blood : the full meaning of which (a well known fact, and
not without parallel) may be thus expressed : — The principal constituents
of the urine are, we know, ready formed in the blood, and are separated
through the kidneys by the development, growth, and discharge of the
renal cells in which they are, for a time, incorporated. Now, when one
kidney is destroyed, there must for a time be an excess of the constitu-
ents of urine in the blood; for since the separation of iu*ine is not mere
filtration, the other kidney cannot at once, and without change of size,
discharge a double quantity. What, then, happens ? The kidney grows ;
more renal cells developc, and discharge, and renew themselves ; in other
words, the existence of the constituents of the urine in the blood that is
carried to every part determines the formation of the appropriate renal
organs in the one appropriate part of the body.
An analogous fact is furnished by the increased formation of adipose
tissues in consequence of the existence of abundant hydro-carbon princi-
ples in the blood. Another, bearing on the same point, though not ad-
mitting of definite description, is the influence exercised by various diets
in favoring the especial growth of certain tissues ; as the muscles, the
bones, the hair, or the wool. Similar facts are yet more evident in the
cultivation of vegetables, to which various materials are supplied, in the
assurance that certain corresponding tissues will be consequently formed.
And an evident illustration of the same principle is in the abundant for-
mation of fruit on a branch in which the matured sap has been made to
accumulate by ringing.
I add again, on this point, as on a former one, that the case as con-
cerning nutrition is remarkably corroborated by the observation of similar
facts in instances of secretions. Thus, the excesses of albuminous mate-
rials taken in food, if they be not incorporated in the more highly orga-
nized tissues, are excreted ; that is, they, or the materials into which they
are transformed, enter into the construction of the transient tissue of the
kidney or some excretory organ. The constituents of food, plainly as
they influence the quantity and quality of milk, do so only by affecting,
after their admission into the blood, the formation of the transient parts
of the mammary gland-tissue. Medicines, such as diuretics, that are
8
84 CONDITIONS KECBSSABY TO
separated from the body by only certain organs, are, for a time, we must
believe, incorporated in the tissues of those organs.
These facts seem enough to make highly probable the principle I men-
tioned— namely, that the existence of certain materials in the blood may
determine the formation of structures into the composition of which those
materials may enter. At any rate we make it nearly certain for the
more lowly organised tissues, and for the products of disease ; and hence,
by analogy, we may assiune it for the other tissues. Even for the very
highest, we may safely hold that a necessary condition of their formation
is this previous existence of the peculiarly appropriate materials in the
blood.
Now, if we combine these two principles — first, that the blood is defi-
nitely altered by the abstraction of every material necessary for the nu-
trition of a part, and secondly, that the existence of certain materials in
the blood induces the formation of corresponding tissues, we may derive
from them some very probable conclusions bearing on the questions before
us. First, we may conclude that the order in which the several organs
of the body appear in the course of development, while it is conformable
with the law of imitation of the parent, and with the law of progressive
ascent towards the higher grade of being, is yet in part, and in this more
directly, the result of necessary and successive consequences : the forma-
tion of one organ, or series of organs, inducing, or supplying a necessary
condition for, the formation of others, by the changes successively pro-
duced in the composition of the blood or other nutritive material. In
other words, we may hold, in accordance with these principles, that the
development of each organ or system, co-operating with the self-develop-
ment of the blood, prepares it for the formation of some other organ or
system ; till, by the successive changes thus produced, and by its own de-
velopment and increase, the blood is fitted for the maintenance and nutri-
tion of the completed organism.
Secondly, I think that these principles may be applied to individual
instances. They may suggest that certain organs stand, in their nutri-
tion, in a complemental relation to each other ; so that neither of them
can be duly formed, or maintained in healthy structure, unless the right
condition of the blood be induced and preserved by the formation of the
other.
It is, of course, very difficult, or even impossible, to find instances by
which this theory of complemental nutrition can be proved ; while, really,
wd neither know exactly what materials are necessary for the formation
of any organ, nor have the means of detecting the presence of more than
a very few of them in the blood. It is very well for the discussion of
certain parts of physiology to say, for instance, that a muscle mainly
consists of a material like fibrin ; but when we are considering the phy-
siology of the formation of organs, we must remember that in every mus-
cular fibre there are at least three different compounds — those of the sarco-
HBALTHT NUTRITION. 35
lemma, of the nucleus, and of the fibril ; that these are all equally essential
to the fonnation of the fibre ; and that we know not the composition of
any one of them, nor could detect the absence of any one of them from
the blood, though the result of that absence might be to render the forma-
tion of a muscular fibre impossible.
But, though it may lack direct evidence, the theory seems, in itself,
probable ; and there are many facts which we can explain by it so well,
that they become evidence for it : — ^which facts, moreover, are fair sub-
jects for theoretical explanation, since, I believe, they are admitted to be
as yet wholly imexplained.
Among these is the general fact that a great change in nutrition rarely
takes place in one organ at a time, but usually afiects simultaneously two
or more parts, between whose nutrition there is a manifest and constant
connection, although there is little or no relation between their external
functions. Such, to take an instance from a large class, is the connec-
tion between the growth of various appendages of the integuments, and
the development or maintenance of the genital organs. This appears to
be a general rule. The growth of the beard at the period of puberty in
man, with which we are so familiar, is more instructively represented in
many animals : especially in birds. In these, as you know, at the ap-
proach of every breeding time, the genital organs begin to develope them-
selves for the season, as in man they do for the whole time of vigorous
life. And, commensurately with this development, the plumage (espe-
cially in the male bird), becomes brighter and more deeply colored, both
by the growth of new feathers, and by the addition of color to the old
ones. The height and perfection of the plumage are coincident with the
full development and activity of the reproductive organs ; but as in man,
when the development of the genital organs is prevented, the develop-
ment of the beard and all the other external sexual characters, is, as a
consequence, hindered, so, in the birds, when the breeding season ends,
and the sexual organs pass gradually into their periodic atrophy, at once
the plumage begins to assume the paler and more sober colors which
characterize the barrenness of winter.
So it is, also, at least in certain instances, in the mammalia, of which
we have interesting evidence in the history of specimens presented to the
museum of the College by Sir Philip Egerton. These show that if a buck
be castrated while his antlers are growing and still covered with the velt,
their growth is checked, they remain as if truncated, and irregular
nodules of bone project from their surfaces. Or, if the castration be
performed when the antlers are full-grown, these, contrary to what Redi
said, are shed nearly as usual, at the end of the season ; but in the next
season, only a kind of low conical stumps are formed in the place of
antlers.*
* This formation of imperfect antlers may depend on the accessory organs of reproduction
being dereloped ; for these would not necessarily fail to be developed because the testicles
86 CONDITIONS NECB8SART TO
I need not multiply examples : it is a general fact, that the develop-
ment and activity of the reproductive organs have, as a consequence, or
as a necessary coincidence, a peculiar development and active growth or
nutrition of certain other structures; which structures^ therefore, form
the external sexual characters, though their external functions stand in
no apparent, often in no conceivable, connexion with the generation of
the species. The fact is not hitherto explained ; it is explicable, on the
theory of complemental nutrition, by believing that the materials which,
in the formation of these organs of external sexual character, are re-
moved from the blood, leave or maintain the blood in the ^tate necessary
for the further development, growth, and active function of the proper
sexual or reproductive organs. In other words, I would say, that where
two or more organs are thus manifestly connected in nutrition, and not
connected in the exercise of any external oflSce, their connexion ifi because
each of them is partly formed of materials left in the blood on the forma-
tion of the other ; and each, at the same time that it discharges its own
proper and external office, maintains the blood in the condition most
favorable to the formation of the other.
If this theory be fidmissible, we may find through it the meaning of
the commensurate development and nutrition of many other organs,
which in their external functions appear unconnected. Such are the
concurrent development and activity of the thymus gland and the air-
breathing organs, during the body's growth ; of the thyroid gland and
the brain (instances of commensurate development cited by Mr. Simon);*
of the spleen and pancreas (as pointed out by Professor Owen) ; and, I
would add, of the embryo and the mammary gland ; for the same theory
may. hold true concerning the formation of certain organs which are,
finally, connected in their external functions.
In these, and other like cases, I think it will be hereafter proved that
the several organs are, in their nutrition, complemental ; that the forma-
tion of each leads to the production of some material necessary for the
construction of the other ; and that, as we ipay be sure of Treviranus'
law, in general — that each organ of the body, while it nourishes itself, is
in the character of an excretion towards all the rest, — so, we may believe,
more particularly, that certain organs are, mutually, as excretions from
each other.
But, thirdly, if there be any probability in the principles I have endea-
vored to illustrate, they must deserve careful consideration in the patho-
logy of the blood. I shall have to illustrate them in this view in future
lectures. At present I will only suggest,- that if each part, in its normal
nutrition, is as an excreting organ to the rest, then the cessation or per-
were extirpated. And that the difference caused by castration is not due to the disturbance
of nervous sympathies, is proved by the absence of any similar effect when the testes are
only transplanted. See Berthold in Mailer's Archiv., 1840, p. 4*2.
* Essay on the Thymus Gland ; and Philosophical Transactions, 1844, Part 2.
HEALTHT NUTKITION. 87
version of natrition in one must, by no vague sympathy, but through
definite change in the condition of the blood, affect the nutrition of the
rest, and be thus the source of ^'constitutional disturbance." If, in
health, there be such a thing as complemental nutrition, it must, in dis-
ease, be the source of many sympathies in nutrition between parts which
are not specially connected through the nervous system. If the condi^
tion of the blood can, in favorable circumstances, determine the forma-
tion of organisms incorporating its materials, we may study the characte-
ristic structures of specific diseases as the evidences of corresponding
conditions of the blood, and as organs which, by removing specific mate-
rials from the blood, affeict its whole constitution, and either restore its
health, or produce in it secondary morbid changes.
The extent of application that these principles admit of will, I trust,
justify the distance to which I may seem to have diverged from my
starting-point. Let me now return to it, and remind you that this long
discussion grew out of the consideration of the first condition necessary
for healthy nutrition, — namely, the right state of the blood ; a state not
to be described merely as purity, but as one of exact adaptation to the
peculiar structure and composition of the individual : an adaptation so
exact that it may be disturbed by the imperfect nutrition of a single
organ, and that for the maintenance of it, against all the disturbing
forces of the outer life of the body, nothing can suffice except continual
readjustment by the assimilative power of the blood itself.
The second condition of which I spoke as essential to the healthy pro-
cess of nutrition, is —
A regular supply of appropriate blood in or near the part to be
nourished.
The proofs of the necessity of this condition must be familiar to all.
Instances will at once occur to your minds, in which too little blood
being sent to a part, it has suffered atrophy : others, in which the supply
being wholly cut off, mortification has ensued : others, in which the blood
being stagnant in a part, has not efficiently contributed to its nutrition.
If I can give interest to this part of the subject at all, it is only by
adducing interesting examples of the fact. Reserving for future lectures
the examples of merely diminished and of perverted nutrition, I will men-
tion now only some of the specimens in the Museums I have chiefly
studied, which illustrate how the process of nutrition is wholly stopped
by the absence or deficiency of fresh blood.
One of Mr. Swan's donations to the College Museum (No. 1821), is
the larynx of a man who, while in low health, cut his throat, and suffered
so great a loss of blood that the nutrition became impossible in one of
those parts to which blood is most difficultly sent ; and before he died,
his nose sloughed.
The case is like one which, you may remember, is recorded by Sir
88 CONDITIONS NECBSSABT TO
Benjamin Brodie.'*' A medical man wished to be bled, in a fit of exceed-
ing drunkenness ; and some one bled him, — ^bled him to three pints. He
became very ill, and next day both his feet were mortified, from the
extremities of the toes to the instep.
A specimen (No. 141), presented by Mr. (Juthrie, exhibits a mortified,
i, e.y a completely unnourished leg, from a case in which the femoral
artery was obliterated near the groin through disease of its coats. The
leg was amputated by Mr. Guthrie with justifying success ; for the stump,
though cut at some distance below the obliteration of the artery, did not
slough; the collateral circulation was sufficient for its nutrition; and the
patient, an. elderly lady, died only of exhaustion.
For a similar, and very rare, example of sloughing after the obliterar
tion of a main artery, I may refer to the case, described by Mr. Vincent,
of a large slough in the very substance of one of the hemispheres of the
cerebrum, in consequence of a wound of the supplying common carotid,
— a wound made by a tobacco-pipe thrust into the bifurcation of the
carotid, and nearly closing its channel.f
A specimen in the Museum of St. Bartholomew's Hospital (Series i.
184) exhibits an instance of dry gangrene occurring in very imusual cir-
cumstances. A woman, 48 years old, died, under the care of Mr. Earle,
having received some injury of the femur eighteen months before death.
Whether it were a fracture, or, indeed, what it was, cannot now be said ;
but the injury was followed by enlargement of that portion of the wall of
the femur with which the artery and vein are nearly in contact, as they
pass in the sheath of the triceps adductor muscle. At this part, then,
the vein is compressed, and the artery, though not distinctly compressed,
appears to have been hindered from enlarging. The consequence was
dry gangrene of the leg, which slowly destroyed life, and which had no
other apparent cause than this.
And, lastly, let me refer to two specimens, which are as interesting in
the history of surgery as in pathology. One is a tibia and fibula, the
lower ends of which, together with the whole foot, perished in consequence
of the obstruction of the circulation by an aneurism in the ham. It is an
Hunterian specimen in the College Museum (No. 710); and surely we
may imagine that sometimes Mr. Hunter would contemplate it with
pride, to think how rare such things would be in after times ; for here is
a strong contrast : the limb of a man who once had an aneurism, like the
one which in the former case was so destructive, and on whom Hunter
was permitted to confer fifty years of healthy life by his operation of
tying the artery at a distance from the diseased part. The Museum of
St. Bartholomew's owes this rare specimen and most interesting relic to
the zeal of my colleague, Mr. Wormald. The patient was the fourth on
whom Mr. Hunter performed his operation. He was 36 years old at the
• Lectures on Pathology and Surgery, p. 350.
f Medico-Chinirgical Transactions, Vol. xxix., p. 38.
HEALTHY NUTRITION. 89
time ; and though the tumor was not large, yet the whole leg was swollen,
the veins were tnrgid, and he was exhausted, and in such bad health, that
the case seemed desperate ; but he recovered, and lived, as I have said,
fifty years. The artery was tied in the sheath of the triceps muscle ;
and in this operation, for the first time, Mr. Hunter did not include the
vein in the ligature. He thus diminished exceedingly the danger of the
defective supply of arterial blood. The preparation shows the whole
length of the artery obliterated from the origin of the profunda, to that
of the anterior tibial, and the aneurismal sac, even after fifty years, not
yet removed, but remaining as a hard mass like an olive."*"
Now, the supply of appropriate blood, of which these specimens prove
the necessity, must be in or near the part to be nourished. We cannot
exactly say how near it must be, but, probably, all that is necessary is,
that Hie nutritive material should admit of being imbibed in sufficient
quantity into the substance of the part. For imbibition must be regarded
as the means by which all parts supply themselves with nutritive matter :
thus deriving it from the nearest blood-vessels, and the blood-vessels
themselves being only the channels by which the materials are brought
near. The blood-vessels thus serve alike for the nutrition of the vascular,
and, as we call them, the non-vascular, parts, the difference between
which parts, in this regard, is really very little. For the vascular, the
nutritive fluid is carried in streams into their interior ; for the oth^r it
flows on one surface : but in both alike, the parts to be nourished have to
imbibe the nutritive fluid ; and though the passage through the walls of
the blood-vessels may effect some unknown change in the materials, yet
all the business of formation is, in both alike, outside the vessels. Thus,
in muscular tissue, the fibrils in the very centre of the fibre nourish them-
selves; yet these are distant from all blood-vessels, and can only by
imbibition receive their nutriment. So, in bones, the spaces between the
blood-vessels are wider than in muscle ; yet the parts in the spaces nourish
themselves, imbibing materials from the nearest source. And the non-
vascular epidermis, though no vessels pass into its substance, similarly
imbibes nutritive matter from those of the immediately subjacent cutis,
and maintains itself, and grows. The instances of the cornea, the vitreous
humor, and the peripheral part of the mnbilical cord, are stronger, yet
similar.
There is, therefore, no real difference as to the mode in which these
tissues obtain their nutriment : and, sometimes, even the same tissue is
in one case vascular, in the other not; as the osseous tissue, which,
usually, when it is in masses or thick layers, has blood-vessels running
into it ; but when it is in thin layers, as in the lachrymal and turbinated
bones, has not. These thin bones subsist on materials from the blood
• The preparation is in Set. 13, Sub-Ser, F. No. 4. The case is in the " Transactions of a
Society for the Improvement of Medical and Surgical Knowledge," Vol. i., p. 138; and in
Homers Works, Vol. iii., p. 604.
40 CONDITIONS NEOBBSARY TO
flowing in the minute vessels of the mucous membrane, from which, on
the same plan, the epithelium derives nutriment on one side, the bone on
the other, and the tissue of the membrane itself on every side.
It is worth while to remember this, else we cannot understand how
the non-vascular tissues, such as the cornea, the hair, the articular carti-
lages, and the various cuticles, should be liable to diseases proper to
themselves, primarily and independently. And, except by thus consider-
ing the subject, we shall not be clear of the error and confusion which
result from speaking of the "action of vessels;" as if the vessels really
made and immade the parts. We have no knowledge of the vessels as
anything but carriers of the materials of nutrition to and fro. These
materials may, indeed, undergo some change as they pass through the
vessels' walls ; but that change is not an assuming of definite shape ; the
vessels only convey and emit the "raw material;" it is made up in the
parts, and in each after its proper fashion. The real process of forma-
tion of tissues is altogether extra-vascular, even, sometimes, very far
extra-vascular ; and its issue depends in all cases chiefly, and in some
entirely, on the aflSnities (if we may so call them) between the part to be
nourished and the nutritive fluid.
The third condition essential to the healthy nutrition of parts, is a cer- .
tain influence of the nervous system. It may be held, I think, that, in
the higher vertebrata, some nervous force is habitually exercised in the
nutrition of all the parts in or near which nerves are distributed ; and
that it is exercised not merely in affecting or regulating the size of the
bloodvessels of the part, but, with a more direct agency, as being one of
the forces that concur in the formative process.
Of late years, a current of opinion has run against the belief of this ;
and, of those who admit some influence of the nervous system upon the
nutrition of parts, many do it, as it were, grudgingly and doubtfully.
They hold that at most the influence is exercised only indirectly, through
the power which the nervous system has of affecting the size of the blood-
vessels ; or that the nervous system influences only the degree, without
affecting at all the mode of nutrition in a part.
One chief argument against the belief that the nervous force has a
direct and habitual influence in the nutritive processes is, that in plants and
the early embryo, and in the lowest animals in which no nervous system
is developed, all nutrition goes on well without it. But this is no proof
that in animals which have a nervous system, nutrition is independent of
it ; rather, even if we had no positive evidence, we might assume that in
ascending development, as one system after another is added or increased,
so the highest, and, highest of all, the nervous system, would be inserted
and blended in a more and more intimate relation with all the rest.
This would, indeed, be only according to the general law, that the inter-
dependence of parts augments with their development : for high organi*
nSALTHY NUTRITION. 41
sation consists not in mere multiplication or diversity of independent
parts, but in the intimate combination of many parts in mutual main-
tenance.
Another argument implies that the nervous force can manifest itself
in nothing but impressions on the mind, and muscular contraction-force.
So limited a yiew of the convertibility of nervous force, is such an one
as the older electricians would have held, had they maintained that the
only possible manifestations of electricity were the attractions and re-
pulsions of light bodies, or that the electric force could never be made
to appear in the form of magnetism, of chemical action, or of heat. We
are too much shackled with these narrow dogmas of negation. The evi-
dence of the correlation and mutual convertibility of the physical forces
might lead us to anticipate a like variety of modes of manifestation for
the nervous and other forces exercised in the living body.* We might
anticipate, too, that, as the nervous force has its origin in the acts of
nutrition by which the nerve substance is formed, so, by reciprocal ac-
tion, its exercise might affect the nutritive acts. As (for illustration
sake) the completed blood affects all the processes by which itself was
formed, so, we might suppose, would the nervous force be able to affect
all the acts of which itself is the highest product.
But we need not be content with these probable deductions concerning
the direct influence of the nervous force on the nutritive process. The
facts bearing on the question seem sufficient for the proof.
A first class of them are such as show the influence of the mind upon
nutrition. Various conditions of the mind, acting through the nervous
system, and by nervous force, variously affect the formative processes in
the whole body. There is scarcely an organ of nutrition of which may
not be thus affected by the mind. It is hardly necessary to adduce ex-
amples of a fact so often illustrated ; yet I may mention this one : — Mr,
Lawrence removed, several years ago, a fatty tumor from a woman's
shoulder ; and, when all was healed, she took it into her head that it was
a cancer, and would return. Accordingly, when by accident I saw her
some month afterwards, she was in a workhouse, and had a large and
firm painful tumor in her breast, which, I believe, would have been re-
moved, but that its nature was obscure, and her general health was not
good. Again, some months afterwards, she became my patient at the
Finsbury Dispensary : her health was much improved, but the hard lump
in her breast existed still, as large as an egg, and just like a portion of
indurated mammary gland. Having heard all the account of it, and how
her mind constantly dwelt in fear of cancer, I made bold to assure her,
by all that was certain, that the cancer, as she supposed it, would go
away : and it did become very much smaller without any help from
medicine. As it had come imder the influence of fear, so it very nearly
* See Carpenter on the Mutual Relation of the Vital and the Physical Forces, Phil. Trans.,
1850, and General Physiology, p. 34.
42 CONDITIONS NECBSSABY TO
disappeared under that of confidence. But I lost sight of her before the
removal of the tumor waa complete.
The other classes of cases are those in which the influence of the
nervous system alone, independent of the Mind, is shown. Of course,
such cases can only be drawn from those of abstraction or perversion of
the nervous influence ; and the effects of these are most plainly expressed
in the nutrition of parts exposed to external agencies, as the integu-
ments generally, the extremities, and other external parts: but we may
fullj believe, that what is observed in these, occurs also, in correspond-
ing measure, in more deeply-seated parts.
Now, for the result of the abstraction or diminution of nervous force,
I cite the following from among many similar facts : — In the Museum of
St. Bartholomer's (Ser. 9, No. 9) is an example of central penetrating
ulceration of the cornea, in consequence of destruction of the trunk of
the trigeminal nerve, by the pressure of a tumor near the pons.* The
whole nutrition of the corresponding side of the face was impaired ; the
patient had repeated attacks of erysipelatous inflammation, bleeding from
the nose, and, at length, destructive inflammation of the tunics of the eye,
and this ulceration of the cornea.
In the College museum (No. 2177) is the hand of a man, whose case
is related by Mr. Swan, the donor of the preparation. The median nerve,
where it passes under the annular ligament, is enlarged, with adhesion
to all the adjacent tissues, and induration of both it and them. A cord
had been drawn very tight round this man's wrist seven years before the
amputation of the arm. At this time, it is probable, the median and
other nerves suffered injury ; for he had constant pain in the hand after
the accident, impairment of the touch, contraction of the fingers, and
which bears most on the present question) constantly repeated ulcera-
tions at the back of the hand.
Mr. Hilton has told me this case : — ^A man was at (Juy's Hospital,
who, in consequence of a fracture of the lower end of the radius, re-
paired by an excessive quantity of new bone, suffered compression of the
median nerve. He had ulceration of the thumb and fore and middle
fingers, which resisted various treatment, and was cured only by so bind-
ing the wrist that, the parts on the palmar aspect being relaxed, the
pressure on the nerve was removed. So long as this was done, the ulcers
became and remained well ; but as soon as the man was allowed to use
his hand, the pressure on the nerves was renewed, and the ulceration of
the parts supplied by them returned.
Mr. Traversf mentions a case in which a man had paraplegia after
fracture of the lumbar vertebrae. He fractured at the same time liis
humerus and his tibia. The former, in due time, united : the latter did
not.
* The case is related by Mr. Stanley in the Medical Gazette, Vol. i. 531.
t Further Inquiry concerning Constitutional Irritation, p. 430.
HBALTHT NUTRITION. 48
Mr. De Morgan"^ has related a similar case. A man fractured his
twelfth dorsal vertebra, and crushed the cord ; dislocated his left hu-
merus, and fractured fourteen ribs and his left ancle. He lived eighteen
days, during which the reparative process was active at the injuries
above the damage of the cord, but seemed to be wholly wanting at those
below it.
Sir B. G. Brodie mentions having seen mortification of the ankle begin
within twenty-foui: hours after an injury of the spine.f
It would be easy to multiply facts of this kind, without adducing in-
stances of experiments on lower animals, which, though they be corrobo-
rative, cannot be fairly applied here. I will only refer in general to the
numerous recorded examples of the little power which paralysed parts
have of resisting the influence of heat ; of the sloughing after injury
of the spinal cord ; of the slower repair and reproduction of parts whose
nerves are paralysed or divided ; all which facts alike contribute to prove,
that the integrity of the nervous centres and trunks which are in anato-
mical relation with a part, is essential to its due nutrition, or, to its ca-
pacity of maintaining itself against the influence of external forces, which
capacity is itself an expression of the formative power.
Lastly, for cases illustrating the effects produced in nutrition by dis-
turbances of the nervous force, I must refer to the Lectures on Inflam-
mation. At present, I can only allude to the cases of inflammation of
the conjunctiva excited by stimulus of the retina ; or inflammation of the
testicle in consequence of mechanical irritation of the urethra ; of the
vascular congestion which is instantly produced around a killed or in-
tensely irritated part, or in and around a part in which paroxysms of
neuralgia are felt ; of the inflammations whose range seems to be deter-
mined by the course or distribution of nerves, as in Herpes Zona. In all
these cases, I know no explanation for the disturbance of nutrition, except
that it is the consequence of the nervous force in the part being directly,
or by reflection disturbed.
The value of all these facts is strengthened by the consideration of the
manifold and distinct influences of the nervous force upon secretion ; for
the process of secretion is so essentially similar to that of nutrition, that
whatever can be proved of the method of one might be inferred for that
of the other. And I think the proof of the direct influence of the ner-
vous force upon the formative process would be thus beyond question,
if it were not for the inconstancy of the results of injury of the spinal
cord and nerves. Even in the warm-blooded animals the division of the
cord does not always retard the healing of injuries in the paralysed
limbs ; sometimes it scarcely affects any part of their nutrition ; and
even in man, healing may be effected in paralysed limbs after injuries,
though they be produced by such trivial causes as would not have dis-
* London Medical and Surgical Journal, January 4th, 1834.
f Lectures on Padiology and Surgery, p. 309.
44 CONDITIONS NECESSARY TO
turbed the nutrition of sound limbs. I remember a man ^ith nearly
complete paraplegia and distorted feet, the consequence of injuries of
the spine, in whom some tendons were subcutaneouslj divided, and ap-
peared to be healing ; but a bandage being applied rather tightly, slough-
ing ensued at the insteps, on which the chief pressure fell, and extended
widely and deeply to the ankle joints. Both the dorsal arteries were
laid open when the sloughs separated, and both the ankle joints, and the
case presented a most striking example of the defective self-maintenance
of paralysed parts. But granulations formed after the separation of the
sloughs, and the healing process went on slowly, but uninterruptedly,
till all was covered in with a well-formed scar. In another case, a girl,
with softening of the brain, had sloughs on nearly every part of the body
that was subject to even slight pressure : for instance, on the back of her
head resting on the pillow, on her elbows and heels ; and yet, while se-
veral of these sloughs were extending with fearful rapidity, an ulcer,
which had remained after the separation of a slough over the patella,
healed perfectly.
Such cases as these seem incongruous in their several parts, and irre-
concilable with the general rules which I previously illustrated : I cannot
attempt to explain them ; but neither can I think that they materially
invalidate the rule.
Let me add, further, that no tissue seems to be wholly exempt from
the influence of the nervous force on its nutrition. In the cuticle it is'
manifest ; and, for its influence in acting even through a considerable
distance, I may mention a case, which is also in near relation to those in
which the hair grows quickly gray in mental anguish. A lady, who is
subject to attacks of what are called nervous headaches, always finds in
the morning after such an one, that some patches of her hair are white,
as if powdered with starch. The change is effected in a night, and in a
few days after, the hairs gradually regain their dark brownish color.
If, now, we may hold this influence of the nervous system to be proved,
we may consider the question, — through what class of nerves is the nu-
tritive process influenced ?
Indirectly, it is certain that the motor or centrifugal nerves may
influence it ; for when these are paralysed, the muscles they supply will
be inactive, and atrophy will ensue, first, in these muscles : then, in the
bones (if a limb be the seat of the paralysis), for the bones, in their nutri-
tion, observe the example of their muscles : and, finally, the want of
energy in the circulation, which is in some measure dependent on mus-
cular action, will bring about the atrophy of the other tissues of the part.
Hence, after a time, the evidences of paralysis of the facial nerve may
be observed in nearly all the tissues of the face.
But the eflfects of destruction of the trigeminal nerve, while the motor
nerves of the parts which it supplies are unimpaired, prove that a more
direct influence is exercised through sensitive or sympathetic nerves.
HBALTHT NUTBITIOK. 45
The olfactory, optic, third, fourth, sixth, and facial nerves, may be one
and all destroyed, yet no disturbance of the nutrition of the nose or eye
may ensue. After destruction of the facial, indeed, there may be inflam-
mation of the eye from irritants, T?hich the paralysed orbicularis palbe-
brarum cannot shut out or help to remove ; but neither this nor any other
injury of these nerves is comparable with the consequences of the destruc-
tion of the trigeminal : consequences which in the rabbit are manifest,
and may be very grave, within a day of the destruction of the nerve, and
may be completely destructive of the eye within three days.
In muiy of these cases it is difficult to say whether the influence on
nutrition is exercised through sensitive nerve-fibres of the cerebro-spinal
system, or through sympathetic (ganglionic) nerve-fibres ; and I think it
is probable that it may be exercised through either.
On the one side we have the fact that the destruction of the eye en-
sues more quickly after division of the trigeminal nerve in front of the
Casserian ganglion, than when the division is made between the ganglion
and the brain. This may imply that filaments derived from the ganglion,
or passing through it from the sympathetic nerve, are those through
which the influence on nutrition is exercised. And their sufficiency is
supported by the fact that great disturbance in the nutrition of the eye
is an ordinary consequence of the extirpation of the superior cervical gan-
glion of the sympathetic, even when the trigeminal nerve is unafibcted.
But, on tlje other side, we have the facts of the destruction of the eye
when the trigeminal nerve is spoiled near its origin, the sympathetic
nerve being sound (as in the case by Mr. Stanley) ; and of the defective
nutrition in consequence of injuries of the spinal cord, when also the
sympathetic centres are uninjured ; as in the cases by Sir B. C. Brodie
and Mr. Travers. For this view, also, is the occurrence of general
atrophy in consequences of diseases of the brain.
Finally, when defective nutrition follows injury of the spinal cord, it
appears to be, directly due to the injury of the sensitive, rather than the
motor, nerve-fibres. Sloughing of the bladder and other parts occurs, I
believe, in such cases earlier and more extensively when sensation, than
when motion alone, is lost. And Mr. Curling has recorded this case :* —
Two men were, at nearly the same time, taken to the London Hospital
with injury of the spine ; one had lost only the power of motion in the
lower extremities ; the other had lost both motion and sensation ; and at
the end of four months the atrophy of the lower extremities in this last
was far more advanced than in the first.
None of these cases, however, enable us to say whether the influence on
nutrition is exercised through sensitive fibres of the cranio-spinal system,
or Uirough sympathetic fibres; nor do I think this question can be yet
determined.
• Metlico-Cliir. Trans Vol. xx. p. 342.
46 CONDITIONS NEGE88ABT TO
The last condition which I mentioned as essential to healthy nutrition,
is a healthy state of the part to be nonrished.
This is, indeed, involved in the very idea of the assimilation which is
accomplished in the formative process, wherein the materials are supposed
to be made like to the structures among which they are deposited : for
unless the type be good, the anti-type cannot be.
In a part which was originally well formed, and with which the three
conditions of nutrition already illustrated have been always present, this
fourth condition will probably be never wanting ; for the part will not of
itself deflect from the normal state. But when any part, or any consti-
tuent of the blood, has been injured or diseased, its unhealthy state will
interfere with its nutrition long after the immediate effects of the injury
or disease have passed away. Just as, in healthy parts, the formative
process exactly assimilates the new materials to the old, so does it in dis-
eased parts : the new-formed blood and tissues take the likeness of the
old ones in all their peculiarities whether normal or abnormal ; and hence
the healthy state of the part to be nourished may be said to be essential
to the healthy process of nutrition.
The exactness of assimilation accomplished by the formative process in
healthy parts has been already, in some measure, illustrated, as preserving
through life certain characteristic differences, even in the several parts
of one organ ; preserving, also, all those peculiarities of structure and of
action, which form the proper features, and indicate the temperament, of
the individual. In these, and in a thousand similar instances, the pre-
cision of assimilation in the formative process is perfect and absolute,
except in so far as it admits of a very gradual alteration of the parts, in
conformity with the law of change in advancing years.
Nor is there less of exactness in the assimilation of which a part that
has been diseased is the seat. For, after any injury or disease, by which
the structure of a part is impaired, we find the altered structure, — ^whe-
ther an induration, a cicatrix, or any other, — as it were, perpetuated by
assimilation. It is not that an unhealthy process continues : the result
is due to the process of exact assimilation operating in a part of which
the structure has been changed : the same process which once preserved
the healthy state, maintains now the diseased one. Thus, a scar or a
diseased spot may grow and assimilate as its healthy neighbors do. The
scar of the child, when once completely formed, commonly grows as the
body does, at the same rate, and according to the same general rule ; so
that a scar which the child might have said was as long as his own fore-
finger, will still be as long as his forefinger when he grows to be a
man.
Yet though this increase and persistence of the morbid structure be
the general and larger rule, another within it is to be^ remembered ;
namely, that in these structures there is usually (especially in youth) a
tendency towards the healthy state. Hence, cicatrices, after long en-
HBALTHT NUTRITION. 47
darsDce, and even much increase, may, as it is said, wear out ; and
thickenings and indurations of parts may give way, and all become again
pliant and elastic.
The maintenance of morbid structures is so familiar a fact, that not
only its wonder, but its significance, seem to be too much overlooked.
What we see in scars and thickenings of parts appears to be only an ex-
ample of a very large class of cases ; for this exactness by which the
formatiTe process in a part maintains the change once produced by dis-
ease, offers a reasonable explanation of the fact that ccrtam diseases
usually occur only once in the same body. The poison of small-pox, or
of scarlet fever, being, for example, once inserted, soon, by multiplication
or otherwise, affects the whole of the blood ; alters its whole composition :
the disease, in a definite form and order, pursues its course ; and, finally,
the blood recovers, to all appearance, its former state. Yet it is not as
it was : for now the same material, the same variolous poison, will not
produce the same effect upon it ; and the alteration thus made in the
blood or the tissues is made once for all : for, commonly, through all
after life, the formative process assimilates, and never deviates from, the
altered type, but reproduces materials exactly like those altered by the
disease ; the new ones, therefore, like the old, are incapable of alteration
by the same poison, and the individual is safe from the danger of in-
fection.
So it must be, I think, with all diseases which, as a general rule,
attack the body only once. The most remarkable instance, perhaps, is
that of the vaccine virus. Inserted once in almost infinitely small quan-
tity : yet, by multiplying itself, or otherwise, affecting all the blood, it
may alter it once for all. For, unsearchable as the changes it affects
may be ; inconceivably minute as the difference must bo between the
blood before, and the blood after, vaccination ; yet, in some instances,
that difference is perpetuated ; in nearly all it is long retained ; by assi-
milation, the altered model is precisely imitated, and all the blood there-
after formed is insusceptible of the action of the vaccine matter.
In another set of diseases we see an opposite, yet not a contradictory,
result. In these, a part once diseased, is, more than it was before, liable
to be affected by the same disease ; and the liability to recurrence of the
disease becomes greater every time, although in the intervals between
the successive attacks the part may have appeared quite healthy. Such
is the case with gout, with common inflammation of a part, as the eye,
and many others, in which people become, as they say, every year more
and more subject to the disease.
I do not pretend to determine the essential difference between the two
classes of disease in these respects, in which they are antipodal ; but in
reference to the physiology of the formative process, they both prove the
same thing, viz., that an alteration once produced in a tissue, whether by
external influence, or by morbid material in the blood, is likely to be
48 CONDITIONS NECES8ABT TO
perpetuated by the exactness of assimilation observed in the formative
process, t. e. by the constant reproduction of parts in every respect pre-
cisely like their immediate predecessors.
But it will be said, the rule fails in every case (and they are not rare)
in which a disease that usually occurs but once in the same body, occurs
twice or more ; and in every case of the second class in which liability to
disease is overcome. Nay, but these are examples of the operation of
that inner, yet not less certain, law, — that after a part has been changed
by disease, it tends naturally, to regain a perfect state. Most often
the complete return is not effected ; but sometimes it is, and the part,
at length, becomes what it would have been if disease had never
changed it.
I will here refer again to what was said in the first lecture concerning
the blood's own assimilative power. After the vaccine and other infec-
tious or inoculable diseases, it is, most probably, not the tissues alone, but
the blood as much or. much more than they, in which the altered state is
maintained ; and in many cases it would seem that, whatever materials are
added to the blood, the stamp once impressed by one of these specific dis-
eases is retained ; the blood, by its own formative power, exactly assimi-
lating to itself, its altered self, the materials derived from the food.
And this, surely, must be the explanation of many of the most invete-
rate diseases ; that they persist because of the assimilative formation of
the blood. Syphilis, lepra, eczema, gout, and many more, seem thus to
be perpetuated : in some form or other, and in every varying quantity,
whether it manifests itself externally or not, the material they depend on
is still in the blood ; because the blood constantly makes it afresh out of
the materials that are added to it, let those materials be almost what
they may. The tissues once affected may (and often do) in these cases
recover ; they may have gained their right or perfect composition ; but
the blood, by assimilation, still retains its taint, though it may have in it
not one of the particles on which the taint first passed : and, hence, after
many years of seeming health, the disease may break out again from the
blood, and affect a part which was never before diseased. And this ap-
pears to be the natural course of these diseases, unless the morbid mate-
rial be (as we may suppose) decomposed by some specific ; or be excreted
in the gradual tendency of the blood (like the tissues) to regain a normal
state : or, finally, be, if I may so speak, starved by the abstraction from
the food of all such things as it can possibly be made from.
In all these things, as in the phenomena of symmetrical disease, we
have proofs of the surpassing precision of the formative process, a preci-
sion so exact that, as we may say, a mark once made upon a particle
of blood, or tissue, is not for years effaced from its successors. And this
seems to be a truth of widest application ; and I can hardly doubt that
herein is the solution of what has been made a hindrance to the re-
ception of the whole truth concerning the connexion of an immaterial
HEALTHT NUTRITION. 49
Mind with the brain. When the brain is said to be essential, as the
organ or instrument of the Mind in its relations with the external world,
not only to the perception of sensations, but to the subsequent intellec-
tual acts, and, especially, to the memory of things which have been the
objects of sense, — it is asked, how can the brain be the organ of memory
when you suppose its substance to be ever changing ? or, how is it that
your assumed nutritive change of all the particles of the brain is not as
destructive of all memory and knowledge of sensuous things as the sudden
destruction by some great injury is ? The answer is, — because of the
exactness of assimilation accomplished in the formative process: the
effect once produced by an impression upon the brain, whether in percep-
tion or in intellectual act, is fixed and there retained ; because the part,
be it what it may, which has been thereby changed, is exactly repre-
sented in the part which, in the course of nutrition succeeds to it. Thus,
in the recollection of sensuous things, the Mind refers to a brain, in
which are retained the effects, or, rather, the likenesses, of changes that
past impressions and intellectual acts had made. As in some way pass-
ing far our knowledge, the Mind perceived, and took cognizance of, the
change made by the first impression of an object acting through the
sense-organs on the brain; so afterwards, it perceives and recognises
the likeness of that change in the parts inserted in the process of nu-
trition.
Yet here also the tendency to revert to the former condition or to
change with advancing years, may interfere. The impress may be gra-
dually lost or superseded, and the Mind, in its own immortal nature un-
changed, and immutable by anything of earth, no longer finds in the
brain the traces of the past.
LECTURE III.
THE NORMATIVE PROCESS: GROWTH.
Having now considered the sources of the impairment to which the
completely formed blood and tissues are prone, and the chief conditions
necessary for the perfection of the formative process by which, notwith-
standing this impairment, they are maintained almost unchanged, I pro-
pose to speak of the process itself.
You may remember that I referred to the impairment, or wear and
tear, of the body to two principal sources — namely, the deterioration
which every part suffers in the exercise of its function ; and the natural
degeneration or death to which every part is subject after a certain
period of existence, iiidependentl^ of. th§ AQ^t]i oy degeneration of the
4* ' ' *
60 THB FORMATIVE PROCESS.
whole body, and, in some measure, independently of the exercise of
function.
The first question, therefore, in the consideration of the nutritive pro-
cess, may be, — what becomes of the old particle, the one for the replace-
ment of which the process of formation is required ? In answer, we must
probably draw a distinction, though we can hardly define it, between the
parts which die, and those which only degenerate, when they have finished
their course. Those which die are cast out entire : those which degene-
rate are disintegrated or dissolved, and absorbed. We seem to have a
good example of this difierence in the fangs of the two sets of teeth.
Those of the deciduous ones degenerate, are transformed so as to become
soluble, and are absorbed ; those of what are called permanent, — ^more
properly, those of teeth which are not to be succeeded by others deriving
germs from themselves^-die, and are cast out entire. And we may pro-
bably hold it as generally true, that, as Mr. Hunter was aware, living
parts alone are absorbed in the tissues : dead parts, it is most probable,
however small, are usually separated and cast out ; and, as the pheno-
mena of necrosis show, this must be accomplished, not by the absorption
of the dead parts themselves, or their borders, but by the absorption or
retirement of the adjacent borders or surfaces of the living parts.
External, merely integumental, parts appear thus to die, and to be
cast out entire from the body ; but we have no certain knowledge of the
changes they may undergo before they die. And with regard to the
changes which take place in the degeneration that precedes absorption of
the old particles, wo have, again, but little knowledge. Chemistry has,
indeed, revealed much concerning the final disposal of the old materials ;
finding their elements in the excretions ; and proving that the process is
one of descent towards simplicity of organic chemical composition ; one
of approximation towards inorganic character ; and, perhaps always, one
accomplished by the agency of oxygen. It has, also, we may safely be-
lieve, found in the muscles some of the substances into which the natural
constituents of the tissues are transformed, before they assume the compo-
sition in which they are finally excreted. Kreatine and kreatinine are,
most probably, examples of such transitional compounds, intermediate
between some of the proper constituents of muscle, and urea or uric acid.
And I think the frequency with which fatty matter is found in degenerate
parts is an indication that it is an usual product of similar transformation
preparatory to absorption, and to the more complete combination with
oxygen in the formation of carbonic acid and water for excretion. How-
ever, while we have so little knowledge of these intermediate or transi-
tional substances, we can only hold it as generally probable, that the
components of the degenerate and out-worn tissues pass through a series
of chemical transformations, which begin in their natural degeneration
before absorption, till they are completed by the oxidation in the blood
which brings the materials to the s^atQiqmropriate^for excretion.
THB FORMATIVE PROCESS. 51
4
With regard to the fonnative portion of the process, — that by which
the old particle, however disposed of, is to be replaced, — ^it is probably
always a process of development ; a renewal, for each particle, of the
process which was in nearly simultaneous operation for the whole mass
in the original development of the tissue. The fibril, for example, which
is to be formed anew in a muscle, passes, most probably, through the
same stages of development as those did which were fir^t formed in the
embryo. We are led to this conclusion, not only by the evident proba-
bihty of the case, but, first, by the analogy of the hair, the teeth, the
epidermis, and all the tissues we can watch ; in all, the process of repair
or replacement is efiected through development of the new parts : and,
secondly, by the existence of nuclei or cytoblasts in, I think, all parts
which are the seats of active nutrition. For these nuclei (such as are
seen so abundantly in strong, active muscles), are not the loitering im-
potent remnants of the embryonic tissue, but apparatus of power for new
formation. Their abundance is, I think, directly proportionate to the
activity of growth. They are always abimdant in the foetal tissues, and
those of the young animal ; so they are in many quickly growing tissues ;
and they are more plentiful in the muscles and the brain than, so far as
I know, any other non-secreting tissue of the adult. It is interesting,
too, and significant in this regard, to notice their absence or infrequency
in the nerve-fibres of the adult, which in so many points are comparable
with the muscular fibres. And I think I may add that their disappear-
ance from a part in which they usually exist is a sure accompaniment
and sign of degeneration.
A subject of very interesting inquiry is involved in the difference
which we may perceive between what may be called nutritive reproduc-
tion and nutritive repetition. I may illustrate my meaning by reference
again to the teeth. In our own case, as the deciduous tooth is being
developed, a part of its productive capsule is detached, and serves as a
germ for the formation of the second tooth ; in which second tooth, there-
fore, the first may be said to be reproduced, in the same sense as that in
which we speak of the organs by which new individuals are formed, as
the reproductive organs. But in the shark, in which we see row after
row of teeth succeeding each other, the row behind is not formed from
germs derived from the row before : the front row is simply repeated in
the second one, the second in the third, and bo on.
It ifl the same in the blood. The new blood-corpuscles, that are being
constantly formed for the renovation of the blood, are not developed
from germs given off from the old ones ; neither are they formed by any
assimilative force exercised by the old ones. By watching the stages of
their construction, we may see that the development of each is an inde-
pendent repetition of the process by which the first were formed. And
80 with the successive developments of ova and epithelial cells, and many
others ; each is developed independently of the rest, and each repeats
the changes through which its predecessor passed.
52 THE FORMATIVE PROCESS.
Probably we shall find hereafter an analogy in -this respect between
tissues and whole animals ; and that, as in the latter, the capacity of
regeneration of lost parts is in direct proportion to the degree in which
the members of the body are only repetitions one of another, so in the
tissues, much of the difiFerence in the degree of repair they severally
undergo, after injuries or diseases, is connected with the ordinary mode
of nutrition by repetition or by reproduction. When the whole cuticle
of a part is removed, it may be again formed by repetition ; but when a
portion of muscle is removed, its germs are taken with it, and it is not
reproduced.
Whether by repetition or reproduction, let it be observed that each
new elementary structure is made, in successive stages, like what the old
one was, not like what it is : as we see in the young hair following the
course of the old one, or as the child is madp like, not what his father is
now, but what he was at his age. The new particle is, therefore, not
made after a present model.
If, now, we turn from the consideration of the method of the forma-
tive process in the maintenance of the tissues, and from that of the con=
ditions under which it is exercised, to inquire into the nature of the forces
which actuate it ; if we try to answer why any structure just new-formed
has assumed nearly the same form as the old structure had which it
replaces ; we may find suggestions for an answer in the three classes of
facts last mentioned. Among these facts we find (1), as detailed in p.
46, that a structure already formed exercises a certain assimilative influ-
ence on organic materials brought into contact or near proximity -with
it; (2), as in p. 22-23, that, in many cases, certain parts of perfect
structures are, as it were, set apart to be or contain the germs of the
next succeeding similar structures, so that, in succession as in likeness,
the new-formed structure may be called a reproduction of the older ; and
(3) that in many cases, as cited in p. 51, and yet more clearly in instances
of repair and reproduction of injured and lost parts, the replacing struc-
tures are formed entirely anew, and independently of both these condi-
tions. In these cases, no model structure is present to which the new-
forming one may be assimilated ; no tissue-germ which, by its development,
may imitate the structure from which itself was derived ; the new struc-
ture seems as if its own inherent properties had determined the form
that it should take.
Resting on the first two classes of facts, it seems to some a sufficient
explanation of the process of maintenance, to say that each structure in
the body has the power of taking from the blood, by a kind of elective
affinity, certain appropriate materials, and of so influencing them that
they assimilate themselves to it ; i, e., that they adopt or receive its form
and properties, and incorporate themselves with it. By others, it is
held that each cell or structural element of a part, while developing
itself into some higher form, leaves behind or produces tissue-germs, or
THE FORMATIVE PROCESS. 68
off-shoots, which, of course, pass through the same development as itself,
and in due time succeed to its place and office.
Nowj without doubt, the existence of these things is justly assumed,
and we may, by reference to them, express correctly a part of the pro-
cesses by which the maintenance of the body is accomplished. Still it
is, I think, clear that they are not sufficient for the maintenance of the
body in its perfection. For, in the explanation of all the facts of the
third class cited above, a theory of maintenance of the tissues by assimi-
lation, or by the development of successive tissue-germs or cytoblasts, is
inapplicable, — not merely insufficient, but inapplicable ; for a postulate
of this theory is the existence of a present model or germ for the con-
struction of the forming part ; and in all these cases no such germ or
model can be found. Therefore, finding, in these cases, that the forma-
tive process is accomplished in the maintenance of certain parts, without
either assimilation or a succession of germs, we may assume, I think,
that even where either of these conditions is present, it is only as an
auxiliary of some more constant and sufficient force.
Of this force, by whatever name we designate it, whether as the for-
mative, or the plastic, or, more explicitly, as the force by which organic
matter, in appropriate conditions, is shaped and arranged into organic
structure ; of this force, and of those that co-operate with it, we can, I
think, only apprehend that they are, in the completed organism, the
same with those which actuated the formation of the original tissues, in
the development of the germ and of the embryo. As we have seen that
the new formation of elemental structures in the maintenance of tissues
is a repetition of the process observed in their first development, so we
may assume that the forces operative are the same in both processes.*
Thus, then, for explanation of the maintenance of tissues by the con-
stant formation of nearly similar elemental structures, we are referred
back to the history of their first formation: and we might be content to
rest in the belief that the mystery of the development of a germ is
^olly inscrutable. We can discern in its method only this ; that the
materials of which the impregnated germ first consists, and all that it
* G>nceniing the very nature of such forces, and their correlations, I must refer to the
admirable essays of Mr. Grove (The Correlation of Physical Forces), and Dr. Carpenter
(On the Mutual Relations of the Vital and the Physical Forces). " In speaking of forcti as
possessing an absolute existence, it is not intended," says Dr. Carpenter, " on the one hand
to imply that they are anything else than * affections of matter ;' nor, on the other, to regard
them in any other light than as the direct operation of the Primal All-sustaining Cause.
We can form no conception of matter except as possessing properties^ which, when in action,
give rise to powers or forces; whilst on the other hand, w^e cannot think of forces, except as
operating through some form of matter, of whose properties tliey are the manifestation.
The existence of matter, and the action of the forces to which material phenomena (whether
physical or vital) are attributable, are alike the expressions of the Divine Will ; and our aim
must be limited to the discovery of the plan, according to which it has pleased the Creator
to developc and maintain the existing condition of the universe we inhabit.'' — (General
Physiology, p. 36.)
54 THE FORMATIVS PROCESS.
appropriates, are developed according to the same method as was o\h
served in its progenitors, so that at every stage it is like what .they were
at the same stage. It is in conformity with the same law of formation
according to the example of progenitors, that when the general develop-
ment of the body is completed, each of its parts is still maintained or
gradually changed. In each period of life, the offspring resembles the
parents at the corresponding periods of their life ; and, especially, in
those degenerative changes which ensue in old age, we can discern no
other method, or law, than still the same; that the parental form, and
properties, and life, are imitated or reproduced in the offspring.
Now, can we trace anything further back than this fact ? Probably
not : but we may express it in other terms, which may be more conveni-
ently used in our further inquiries, by saying that each germ derives
from its parents such material properties that, being placed in the condi-
tions necessary for the operation of the formative and other vital forces,
it wiU imitate in all the phases of the life of each of its parts, the changes
through which the corresponding parts passed in the parents. It is con-
venient, and probably right, while we assume the operation of a formative
force, still to refer the method of its peculiar manifestations to the mate-
rial properties of the substances in which it acts. In the case before us,
we may accordingly assume, that peculiar and typical properties are
transmitted from its parents to the materials of each impregnated germ ;
that these determine, imder the operation of the formative force, the
construction of corresponding peculiar and typical forms ; that they are
also communicated to whatever materials capable of organization are
brought within the sphere of the developing germ, so that these also
determine the same, or some definitely related, method of construction ;
and that thenceforward, throughout life, by similar communication or
induction of specific properties in the forming blood or other nutritive
fluid, the same method of formation is maintained in all the tissues.
Unless we thus assume a dependence of form upon composition, of
organic structure upon organic constitution, I think we cannot under-
stand, or even clearly speak of, many of the deflections from the normal
formative process which are due to injury or disease : deflections which,
as we have seen, are maintained in the blood and tissues, and the ten-
dency to which is, in hereditary diseases, transmitted from parent to
offspring ^vith the other properties of the germ.
The sum, then, of the hypothesis concerning the formative processes
in the maintenance of the tissues is as follows : — It is assumed, 1st, that
a certain vital formative, or plastic, or constructing force, is in constant
operation ; 2dly, that the forms assumed, under its influence, depend
primarily, and in greatest measure, on the specific composition and other
properties of the organizable materials taken from the blood ; and, 3dly,
that these properties, transmitted in the first instance from the parent to
the germ, are thenceforward communicated to all the nutritive materials ;
GROWTH. 55
subject, however, to certain progressive changes corresponding to the
development and degenerations of the several tissues.
It is assumed, further, that the taking of materials from the blood, by
each part for its own maintenance, depends, as to quality, en certain
definite relations, or ^^ organic affinities" between the blood and the part;
and as to quantity, on the waste of the part. As to the influence of an
assimilative force, exercised by the tissues already formed, upon the
nutritive naterials placed in them, it is probable that this is not a plastic
or constructive force, but chiefly such an one as, like the assumed catalytic
force, or that of a ferment, affects first the composition of the materials
not yet organized, and thus indirectly affects the form that they assume
in organizing.
I fear I may have seemed to have engaged in a very useless discus-
sion, and to have been talking of words more than of things ; but the
charge will not be made by one who knows the utility of being clear in
the expressions used for the ground-work of teaching ; or who will con-
sider the importance in pathology of the principle that specific organic
structures correspond with, and are determined by, specific organic com-
positions.
I propose now to consider, but as yet only generally, the second
method of the formative process, Growth, in health and in disease.
It consists in the increase of a part, or of the whole body, by addition
of new material like that already existing. The essential characters of
each organ or tissue are maintained, but its quantity is increased, and
thus it is enabled to discharge more of its usual function.
For a general expression of the course of events, we may say that the
development and the growth of the body go on together till all the natu-
ral structures are attained; and that then development ceases, and
growth goes on alone, till the full stature, and the full proportion of each
part to the rest, are gained. But this is only generally true ; for we
cannot say that all development ceases at a determinate period, since
some organs may go on to be developed when many others are complete.
Neither can we assign the period of terminated growth ; since, not only
is the period, even stated generally, very various in different persons,
but, some parts, unless placed in imfavorable conditions of disease, con-
tinue growing to the latest period of life. M. Bizot and Dr. Clendinning
have proved, of the heart and arteries, that their average size regularly
increases, though with a decreasing ratio of increase, from childhood to
old age, provided only the old age bo a lusty one.* And this is a real
growth ; for the heart not only enlarges with advancing years, but its
weight augments, and the thickness of its walls increases ; so that we
may believe it acquires power in the same proportion as it acquires bulk
— ^the more readily, since the increased power is necessary for the
• Croonian Lectures by Dr. Clendinning, Medical Gazette for 1837-8, vol. xxii., p. 450.
66 HTPEBTBOPHY.
increasing difficulties put in the way of the circulation by the increasing
rigidity of the parts.
It may be that the same is true of some other parts. This certainly
is true — ^that any part, after it has attained its ordinary dimensions,
according to the time of life, may grow larger if it be more exercised : in
other words, every part has, throughout life, the power of growing,
according to its particular needs, in correspondence with the degree in
which its function is discharged.
Now, when such growth as this is the result of the natural, though
almost excessive, exercise of a part (as of the limbs, for example, during
hard work), we regard it only as an indication of health, and its result is
admitted to be a desirable accession of strength. But, when such growth
in one part is the consequence of disease in another, it is commonly de-
scribed as a disease ; it bears the alarming name of Hypertrophy ; and it
comes to be a subject of consideration in Morbid Anatomy.
But in both these cases the process of growth is the same, and is
according to the same rules ; and the tendency of the process of genuine
hypertrophy in disease, like that of healthy growth in active exercise, is
always conservative. I say genuine hypertrophy, meaning, under that
term, to include only the cases in which the enlargement of a part is
effected with development or increase of its natural tissue, with retention
of its natural form, and with increase of power. To include all enlarge-
ments under the name of hypertrophy is too apt to lead to misunder-
standing.
The rule, then, concerning hypertrophy is, that so long as all condi-
tions remain the same, each part of the body after the attainment of the
average size, merely retains its state, or, at most, grows at a certain
determinate slow rate ; but when the conditions alter, so that a part is
more than usually exercised in its office, then it manifests a power of
renewing or accelerating its growth. It is as if each healthy part had a
reserve power of growth and development, which it puts forth in the time
of emergency. And the converse is equally true : when a part is less
than usually exercised, it suffers atrophy ; so that the rule may be that
each part nourishes itself according to the amount of function which it
discharges.
We may constantly see this rule in many more examples than I need
refer to. The simplest case that can be cited is that of the epidermis.
In its original formation, even before it has come into relation with the
external world, it is formed on the several parts of the body — take, for
example, the back and the palm of the hand — in different quantity and
kind, adapted to the several degrees in which the cutis it is to protect
will be exposed to pressure, friction, and the influence of other external
forces. And, not only are its original quantity and construction on those
parts different, but its rate of growth is so ; for, though the back of the
hand loses comparatively little by friction or otherwise, yet its epidermis
HTPERTBOPHT. 5T
does not grow tliick ; and though the palm loses more, yet its epidermis
does not grow thin. So, then, hoth in original construction, and in rate
of formation, the epidermis is thus adapted to the amount of function it
has to discharge ; that is, to the amount of protection it has to afford.
But suppose now, that, hy some new handicraft, the amount of exercise
of the epidermis is increased ; its rate of waste is increased in the same
proportion, yet it does not grow thin ; nay, it grows thicker, till it is com-
pletely adapted to protect the cutis from the greater sources of injury to
which it is now exposed : it puts forth, as it were, a reserve-power, which
is enough not only to repair all amoimt of waste within certain limits,
but, further than this, to increase the quantity of the tissue to the amount
required for the discharge of its increased functions.
What we can see in this case of the cuticle, we may be sure of for
other tissues ; for example, in a muscle ; as in a heart, when, by disease
of the valves, an obstacle is put in the way of the circulating blood, and
the heart, or one of its cavities, acts with additional force to drive it on.
But, as we know, the more of action in a muscle, the more the consump-
tion of the tissue, so we might now expect a diminution of the heart. On
the contrary, it enlarges ; it is hypertrophied : the formative process not
only meets the immediate exigencies of the increased consumption of
muscular tissue, but produces enough to act with the additional power
required by the increased diflSculty of the circulation.
Such are the effects of growth in examples of hypertrophy. But, to
meet the increasing difficulties of these and the like cases, a part may do
more than grow; it may develope itself; it may acquire new structures,
or it may improve those of which it is already composed, so as to become
fit for higher fimctions and the exercise of greater power. For example,
in the most ordinary hypertrophy of the heart, the muscular tissue is
developed to more robustness : its fibres become not only larger, or more
numerous, but firmer, more highly colored, and stronger. In the preg-
nant uterus, such fibres are formed as are not seen in the unimpregnated
state : they are, indeed, not a new kind of fibre, but they are so different
in size and shape, and so much more powerful than those which existed
before, that we may justly speak of them as developed. And this change
by development, which in pregnancy is natural, is often imitated in dis-
ease, when, by the growth of fibrous tumors in it, the uterus attains the
size, the structure, and even the full capacity of action, of the pregnant
organ. In several of such cases the uterus has at length imitated the
course of labor, and delivered itself of the tumor by its contractile power.
A similar change, by development and growth of muscular fibres, may
occur in the gall-bladder, the ureter, and, probably, in any other part
that has the smooth muscular fibro-cells.
We have an example of development of a secreting structure in the
bursa, which, as Hunter displayed it, is produced under a corn. The
com itself is the result of a kind of hypertrophy, tending to shield the
58 HTPEBTBOPHT.
cutis from unnatural pressure ; but, itself becoming a source of greater
trouble than that against which it was directed, it gives rise to the de-
velopment of a bursa beneath it, which may, for a time, more effectuallj
protect the joint beneath, by diffusing the pressure over a wider extent
of surface.
All these are examples that this hypertrophy, as we call it, though it
happens in circumstances of disease, is yet in general, so far as itself is
concerned, a process of full and vigorous health, serving to remedy or
keep back the ill effects that would ensue from disease in some other
part. It is, in a less degree than the repair of a fracture or other
mechanical injury, an instance of the truth that we are provided for acci-
dents and emergencies ; framed not merely to live in peace and same-
ness, but to bear disturbances ; to meet, and balance, and resist them,
and, sometimes at least, to counteract them.
The amplified healthiness of the formative process exercised in hyper-
trophy is testified by its requiring a full measure of all the conditions of
ordinary nutrition. It needs healthy and appropriate blood ; and one of
the most interesting studies is to watch the hindering influence of disease
on the occurrence and progress of hypertrophy, especially that of the
heart. In sotne of these cases to which I shall have again to refer, death
seems clearly to be the consequence of impairment of the blood, which
can no longer maintain in the heart the exceeding growth required for
its increased functions.
We find, moreover, very constantly, that, as if to insure suflScient blood
to the grown or growing part, the main arteries and veins belonging to
it are enlarged. This is usually well shown in the enlarged coronary
arteries of the hypertrophied heart ; an instance analogous to the enlarge-
ment of the arteries of the pregnant uterus, and the growing antlers of
the deer, and many others. According to all analogy, we must consider
this increase of the bloodvessels to be secondary. As in the embryo,
parts form without vessels, till, for their further nutrition as their struc-
ture becomes more complex, the passage of blood into their interior be-
comes necessary, so, we may be sure, it is here. It is, indeed, strange that
a part should have the power, as it seems, of determining in some mea-
sure the rate at which blood shall flow into it and through it ; but so
it is, and nearly all examples of hypertrophy are examples of the fact ;
though, as I shall presently have to mention, there are instances in which
hypertrophy is the consequence, not the cause or precedent, of increased
supply of blood.
With the increased supply of blood proportioned to the increased nu-
trition of the growing part, the nerves may also increase ; as in the
pregnant uterus and the hypertrophied heart. So, at least, I believe ; but
probably I need not apologise for evading the discussion of this matter.
The conditions which give rise to hypertrophy are chiefly or only three,
namely —
HTPSETEOPHT. 68
1. The increased exercise of a part in its healthy functions.
2. An increased accumulation in the blood of the particular materials
which a part appropriates to its nutrition or in secretion.
3. An increased afflux of healthy blood.
Of hypertrophy as the consequence of the increased exercise of a part,
I have already spoken generally ; and we need no better examples of it
than the muscles of a strong man's arm, fitted for the very exercise in
which they acquired bulk and power, or the great robust heart of a man
who has Buffered some disease producing obstacle to the movement of
the blood. Both alike are the results of vigorous healthy growth,
brought about by exercise of the part in its proper function.
In a former lecture (page 33) I spoke of the increased growth of the
kidney, and of the adipose and other tissues, when the chief constituents
of their structures exist in excess in the blood. To these I may refer
again as examples of the second kind of hypertrophy. And I just now
mentioned, that although in most cases an increased circulation of blood
is the consequence of hypertrophy, yet there are cases in which the
coarse of events is inverted. The increased flow of healthy blood through
a part, if it be not interfered with by local disease, will give rise to
hypertrophy of the part, or, at least, of some of its tissues.
This fact is shown very well in a specimen (No. 6) in the Museum,
which Mr. Hunter described as ^' a sore which had continued inflamed a
long time, where the increased action has made the hair grow." The in-
teguments, for about an inch round the ulcer, where probably there was
simply increased supply of blood, are covered with thick-set, long, and
rather coarse, dark hairs : while on the more distant parts of the integu-
ments, the hair is paler, more slender, and more vridely scattered.
Similar examples of overgrowth of the hair through increased supply
of blood, assisted probably by more than usual external warmth and
moisture, are frequently seen near the ends of stumps which have
remained long inflamed, and about old diseased joints ; not, indeed, at
the very seat of inflammation, but at some little distance from it, where
the parts share the increased supply of blood, but not the disease of
inflammation. Such cases are often observed on limbs in which fractures
have occurred. I remember one very striking case in the thigh of a
child about five years old. The femur had been fractured near the
middle: the case did not proceed favorably; and imion was not accom-
plished without much distortion. When I saw the child, I was at once
struck with a dark appearance on the thigh : it was all covered with dark
hair, like that of a strong coarse-skinned man ; yet, on the rest of the
body, the hair had all the fineness and softness which are proper to it in
early life.
Similar facts are presented by some cases of transplantation. When
the spur of a cock, for example, is transplanted from the leg to the comb,
which abounds in blood, its growth is marvellously augmented, and it in-
60 HTPEBTBOPHT.
creases to a long, strange-looking mass of homy matter, such as is shown
in two preparations in the Museum of the College. In one (54) the spur
has grown in a spiral fashion, till it is six inches long ; in the other (52)
it is like a horn curved forwards and downwards, and its end needed to
be often cut to enable the bird to bring its beak to the ground in feeding,
and to prevent injurious pressure on the side of the neck.
It is worth observing, that these excessive growths have taken place
on the combs without any corresponding diminution in the growth of the
spurs in their proper places. The legs of these cocks are amply spurred,
though the spur thus reproduced is not so long as that which had not
been interfered with. In one instance, moreover (No. 53), there is an
.excessive production of the homy scales upon the legs, while the homy
spur was also excessively growing on the comb.
I shall have occasion presently to mention cases which make it very
probable that the more complex and vascular tissues, such as the
muscles, integuments, and bones of a limb, can bo thus hypertrophied
by excess of blood. I will now only suggest the probability that the
cases of congenital or spontaneous hypertrophy of a hand, or a foot, or
of one or more fingers, have their origin in some excessive formation of
the vessels, permitting the blood to flow more abundantly through the
part. An enlargement of the radial artery has been observed by Dr.
John Reid* in a case of such hypertrophy of the thumb and forefinger ;
but there is no evidence to determine whether in this case the enlarge-
ment of the artery was previous or subsequent to the excessive growth of
the part.
Whatever be the case in these instances of enlargement, the fact,
which the others show, that well-organized tissue, like hair and horn, is
produced in consequence of simply increased supply of blood, stands in
interesting contrast with the phenomena of inflammation, where no tissue,
or only the most lowly organized, is ever formed. No fact can better
show how far the mere enlargement of the bloodvessels is from consti-
tuting the essential part of inflammation.
Through cases of hypertrophy, such as these, the transition is made to
those which, though they appear to consist in simple increase of natural
texture of the parts, we y(^t must regard as morbid, while wo do not
know that they are adapted to any exigency of the economy. Such are
the simple enlargements of the thyroid, thymus, and prostate glands, of
the spken, and tonsils : such too are some examples of mucous polypi,
and of cutaneous outgrowths, and warty growths of the skin. These all
present an increase of natural textures ; and they may bo instances of
purposive growth, adapted and conservative : but till it is more manifest
that they are so, we must be content, I think, to regard them as occu-
pying a kind of middle ground between the genuine hypertropliics of
* London and Edinburg Monthly Journal of Medical Science, 1843, and in a collection by
Mr. Curling in the Medico^hirurg. Trans, vol. zxviii.
HYPERTBOPHT. 61
which I have been Bpeaking, and the thoroughly morbid outgrowths of
which a part of the claas of tumors is composed.
On another side, there are cases intermediate between hypertrophies
and the results of inflammation, and no line of distinction can be drawn
among them, if we rely on. their anatomical characters alone ; for, in the
lowest degrees of inflammation, the exuded material may be organized
into a very near likeness to the natural tissues, and may thus seem to in-
crease their quantity. If these inflammatory hypertrophies, as they
ha?e been called, can be distinguished from true ones, it is only by their
being unattended with increase of functional power, or fitness for the
part's relations.
LECTURE IV.
HYPERTROPHY.
Let me now further illustrate the general physiology of Hypertrophy,
by adducing some of the specimens in the Museum which exhibit it in the
principal tissues.
The first specimen in the Pathological division of the Museum is an
urinary bladder hypertrophied in consequence of stricture of the urethra.
It affords an admirable instance of genuine unmixed hypertrophy ; for
every part of the bladder is grown large ; it is not contracted as if it had
been morbidly irritable ; and its mucous membrane, without induration
or any similar morbid change, is increased, apparently by simple growth,
to a thickness proportionate to that of the muscular coat.
I adduce this especially as an example of hypertrophy of muscular
tissue, concerning which, instead of adding to what was said in the last
lecture, I will quote Mr. Hunter's account. Referring, perhaps, to this
very specimen, he says, in a passage which I have inserted in the cata-
logue :* " The bladder, in such cases [of obstruction to the passage of
urine], ha\'ing more to do than common, is almost in a constant state
of irritation and action ; by which, according to a property in all mus-
cles, it becomes stronger and stronger in its muscular coats ; and I sus-
pect that this disposition to become stronger from repeated action is
greater in the involuntary muscles than the voluntary ; and the reason
why it should be so is, I think, very evident : for, in the involuntary
muscles, the power should be in all cases capable of overcoming the re-
sistance, as the power is always pcrforifiing some natural and necessary
action ; for whenever a disease produces an uncommon resistance in the
• Vol. i. p. 3 ; and Hunter's Works, ii. 299.
62 HYPERTROPHT OF MUSCLE.
involuntaiy parts, if the power is not proportionally increased, the dis-
ease becomes very formidable ; whereas in the voluntary muscles there is
not that necessity, because the will can stop whenever the muscles cannot
follow ; and if the will is so diseased as not to stop, the power in volun-
tary muscles should not increase in proportion.*'
Nothing, surely, could more appositely, or more exactly, express the
truth concerning hypertrophy of muscle ; and it may be observed, from
what he says in a note, that Mr. Hunter appears to have been the first
who rightly apprehended the nature of this growth of the bladder. He
says, ^^ This appearance was long supposed to have arisen from a disease
of this viscus ; but, upon examination, I foimd that the muscular parts
were soimd and distinct, that they were only increased in bulk in propor-
tion to the power they had to exert, and that it was not a consequence
of inflammation, for in that case parts are blended into one indistinct
mass."
What this specimen shows in the urinary hladder is an example of the
change which ensues in all involuntary muscles under the same circum-
stances. They all grow and acquire strength adapted to the new and
extraordinary emergencies of their case. Thus, the oesophagus, the sto-
mach, the intestinal canal, as often as any portion is the seat of stricture,
display hypertrophy of the muscular coat above the stricture. The
enormous enlargements of the intestinal canal, which gradually ensue
above nearly impassable strictures of the rectum, are not mere dilata-
tions, but growths of the intestinal walls ; the muscular coat augmenting
in power, to overcome, if it may, the increased hindrance to the propul-
sion of the contents, and even the glands and other textures of the
mucous membrane simultaneously increasing.
In a great majority of cases, the hypertrophy of muscles, whether
voluntary or involuntary, is the consequence of an increased obstacle to
their ordinary action. Against this obstacle they exert extraordinary
force, and this induces, indirectly, extraordinary formation of their
tissue. Frequent action of muscles, unless it be also forcible, does not
produce hypertrophy. As Mr. Humphry* says, the heart, though it
may act with unusual frequency for years, yet docs not in these cases
grow larger ; and the muscles of the hands are not generally so large in
mechanics who use great celerity of action, as in those who work with
great force. But action of muscles, if it be at once frequent and forcible,
may produce hypertrophy, even though the action be imhealthy. This
appears to be the case with the bladders, of some children, who suffer
with frequent and very painful micturition, and nearly all the signs of
calculus, but in whom no calculus eidsts. The bladder in such children
is found, after death, exceedingly 'hypertrophied, and there may be no
other disease whatever of the urinary organs. Dr. Golding Bird has
• Lectures on Surgery, in Prov. Med. and Surg. Journal ; Reprint, p. 108.
HTPEBTBOPHT OF BONE. 68
shown that phymosis, by obstructing the free exit of unne, may give rise
to these signs and to extreme hypertrophy of the bladder ; but in some
cases it appears certain that hypertrophy may occur without either phy-
mosis, calculus, stricture, or any similar obstruction. It was so in a case
illustrated in the Museum of St. Bartholomew's (xxvii. 14), in a child
four years old, who had suffered intensely with signs of stone in the
bladder, but in whom no stone existed ; no disease of the urinary organs
could be found, except this hypertrophy of the muscular coat of the
bladder. An exactly similar case has been recently under Mr. Stanley's
care, in which, after exceeding irritability of the bladder, the enlarge-
ment of its muscular coat appeared the only change.
In such cases, the too frequent and strong action of the bladder,
though irritable and unhealthy, seems alone to give rise to hypertrophy
of the fibres. It is, however, possible that the change may be due to
narrowing of the urethra by muscular action. If, for example, the com-
pressors of the urethra, instead of relaxing when the muscular coat of
the bladder and the abdominal muscles are contracting, were to contract
with them, the obstacle they would produce in the urethra would soon
engender hypertrophy of the bladder.
Hunter, whose ingenuity was ever tempting on his intellect and indus-
try, asked himself whether the hypertrophy of the heart were accom-
plished by the addition of new fibres, or by the enlargement of those
that already exist. This question could hardly be determined without
more microscopic aid than Hunter had at his command. But if we may
believe (and there can be no doubt we may) that hypertrophy is, in this
respect also, exactly similar to common growth, the question set by
Hunter has been answered by Harting,* with whom, on this point,
Eollikerf agrees. He has shown that, in the growth of striped muscles,
there is no multiplication, no numerical increase, of the fibres, but an
enlargement of them with addition to the number of the fibrils.
Hypertrophy of bone presents itself in many interesting cases. It is
usually a secondary process, ensuing in consequence of change in a part
with which some bone is intimately connected. Just as in their natural
development and growth, the bones of the skull are formed in adaptation
to the brain, and those of the limbs are framed to fitness for the action
of the muscles ; so, in disease, they submit in their nutrition to adapt
themselves to the more active pairts. Thus, the skull enlarges when its
contents do ; and the bones of the limbs strengthen themselves as the
muscles inserted on them become stronger and more active ; and they do
this in adaptation to the force of the muscles, and not merely because of
the movements they are subject to : for no extent or force of passive
movement would prevent the bones of a limb whose muscles are paralysed
from suffering atrophy.
* Rech. Miciom^triques, 1S45, p. 62. t Mikrosk. Anatomie, 11. 255.
64 HTPBSTROPHT.
In the skull, if in any organ, ire might speak of tro forms of bypeP-
trophy ; eccentric and concentric. When the cranial contents are en-
larged, the skull is hjpertrophied with corresponding angmentation of
its area ; and when the cranial contents are diminished, the skull (at
least in many cases) is also hyper trophieil, but with concentric growth,
and diminution of its capacity.
The first, or eccentric form, is usually the consequence of hydroceph^
lus ; wherein, as the fluid collects and distends the dura mater, so the
skull grows ; still, as it were, striving to attain its purpose, and form a
complete envelope for the expanding brain.
The process of enlargement in these cases is often one of simple
growth, and that, indeed, to a leas extent than it may seem at first sight:
for it is very rarely that the
J*^ *" due thickness of the skull is
attained while its bones are
engaged in the extension of
their superficial area. Hence,
the weight of an hydroce-
phalic skull is not much, if
at all, greater than that of
a healthy one ; a large pa-
rietal bone,* measuring nine
inches diagonally, weighs
only four ounces, while the
weight of an ordinary parietal bone is about three ounces.
It IS interesting to observe in some of these cases, the symmetrical
placing of the Wormian bones, by which the extent of the skull is in a
measure made up Tbcy show how the formative process, though thus
thrown into straits and difficulties yet conforms, both in growth and
development, with the law of symmetry.
It would be yet more interesting if we could certainly trace here
something of conformity with the law of unity of organic type, in the
mode of insertion of these Wormian intercalary bonea, when compared
with those of other animals. It cannot be certainly done ; and yet, in
some of these specimens, there appears (as if in accordance with that
law) a tendency to the formation of the Wormian bones at the posterior
part of the sagittal suture more than in any other part, as if in imitation
of the intei-parictal bones of Rodents. And in the very rare spcci-
menf sketched in tbe above diagram, in the midst of great confusion
of tbe other bones, we find a remarkable bony arch, extending from
between the two frontals to the occipital bone ; occupying, therefore, the
place of a largo interparietal bone, and reminding us of some of the
monkeys, e.g., Ccbus and Jaccbus. We have a somewhat corroborative
• No, 2 in ibe College Museum. t ^'o- 3487 in the same Miisoiim.
or BOHBS. 06
qtecimea in the immense hydrocephalic ekuU of the skeleton from Mr.
Iiiston's MiueDsi (So. 3489), in which the interparietal Wormian bones
are larger than any others.
The hypertrophy of the skull, which may be called concentric, is that
which attends atrophy, with shrinkiog of the brain, or, perhaps, any
disease of the brain in which there is ilimiiiution of its bnlk. la such a
ease it nsnally happens, as was first shown by Dr. Sims,* that the skull
becomes very thick.
All the specimens which I have examined show, howerer, that in these
eases the thickening of the skull is not, in itself, a morbid process ; it
manifests definite purpose ; is usually effected by healthy growth ; and
observes the rules followed in the natural formation of the skull.
Tfaoa, as in first formation, the skull adapts itself to the form and
sise of the brain, or, rather, of its membranes ; only now it does so with-
out representing on its exterior the change which has taken place within.
Hie thickening of the skull is effected by the gradual remodelling of the
innw table and diploe of the bones of the vault ; so that, although the
eztoior of the skull may retain its natoral form and sise, the inner table
grows more and more inwards, as if sinking towards the retiring and
dirinking brain ; not thickening, but simply removing from the outer
table, and leaving a wider space filled with healthy diploe.
Ag*ifi, it is a fact of singular interest, that this thickening, this hyper-
trophy of the skull, most commonly, if not always, takes place especially
and to a greater extent than elsewhere, in the parts of the bones in and
about which ossification commenced in the fcetal state : as if, one might
say, some of the potency that of old brought the foetal membrane of these
parts first into the development of bone, were always afterwards con-
centrated in them ; or as if a reserve-power of growth had its seat in the
same <!entres where was formerly the ori^native power of development.
He fact is shown in
many of the speci- "*' ''
ergy of these old cen-
tres, in the fact that those diseases of bone which are accompanied
with excessive formation, such as morbid thickenings of the skull and
tumors, are, in a large majority of cases, seated in or near the centres of
ofluficatioD ; yoa rarely find them except at the articular ends, or round
* Meilico-Chiiutgical Tratifaclions, voJ. zii., p. 315.
66 HYPEBTBOPHY
the middle of the shaft. The same does not hold of necrosis, rickets,
ulceration, or other diseases indicative of depression of the formative
power of the bone. Rather, as some specimens (Nos. 390-1-2) of ricketty
disease of the skull and femora show, the centres of ossification are re-
markably exempt from the change of structure which has extensively
affected the latter-formed parts.
This peculiarity of the centres of ossification is the more remarkable
when we remember that, in many cases, the thickening of the skull takes
place in persons far past the middle period of life ; it may happen even
in very old age, and may give one more evidence of that precision of
assimilation which maintains, throughout life, characteristic distinctions
among portions of what we call the same tissue.
Let me, however, remark, that it is not peculiar to old persons : I be-
lieve that at whatever age, after the complete closure of the cranial su-
tures, shrinking of the brain may happen, this hypertrophy of the skull
may be its consequence. One specimen, for instance (No. 379), is part
of the skull of a suicide, only thirty years old : another (No. 880), from
an idiotic woman, has not the characters of an old skull. I once examined
a remarkable case, showing the same conditions, in a person less than
thirty years old in whom the thickening of the skull must have begun in
early life. She was a lady of remarkable personal attractions, but of
slenderly developed intellect, whose head did not, externally, appear
below the average female size. Yet her cranial cavity was singularly
contracted ; the skull had adapted itself to an imperfectly grown brain,
by the hypertrophy of its diploe, which was nearly half an inch thick at
and near the centres of ossification of the frontal and parietal bones.
Such hypertrophy, however, is not always the mode by which the skull
is adapted to the diminished size of the brain. In congenital and very
early atrophy of the brain, the skull is proportionally small, and may
exactly represent the size and shape of the cerebrum. It does so in the
cases of small-skulled idiots, and in a remarkable skull in the Museum of
St. Bartholomew's Hospital. The man from whom this skull was taken,
received a compound fracture of the left frontal bone when he was only
14 years old. Portions of bone were removed ; hernia cerebri ensued,
and several pieces of brain were sliced ofi". But he recovered and lived
thirty-three years. The left hemisphere of the cerebrum was altogether
small. Where the brain had been sliced ofi", its surface had sunk in very
deep, and had left a cavity filled with a vascular spongy substance con-
taining ill-formed nerve-fibres. You will observe here, that in the model-
ling of the skull, the left side has become in every part less capacious
than the right, adapting itself to the diminished brain without any hyper-
trophy of the bones.
The cases are very rare in which hypertrophy of any other bones than
those of the skull occurs in connexion with what is recognised as disease.
OF BONES. 67
For, as I have said, the bulk of most of the other bones is principally
determined by the activity of the muscles fixed on them ; and a morbidly
excessive action of the muscles, sufficiently continued to produce hyper-
trophy of bones, is seldom, if ever, met with.
But there is a condition of bones so similar to hypertrophy in many
respects, and so little different from it in any, that I may well speak of
it here ; yet not without acknowledging that nearly all I know about it
IB derived from Mr. Stanley.
When any of the long bones of a person who has not yet attained full
stature is the seat of disease attended with unnatural flow of blood in or
near it, it may become longer than the other or more healthy bone.
For example, a lad, suppose, has necrosis of the femur, it may be of a
small portion of it, and he may recover completely from this disease ; but
for all his life afterwards (as I had constant opportunity, once, of observ-
ing in a near relative), he may be lame, and the character of his lame-
ness will show that the limb which was diseased is now too long ; so that
he is obliged, in walking, to lift the lame leg, almost like a hemiplegic
man, lest his toe should trip upon the ground.
Such cases are not uncommon: I once saw, with Mr. Stanley, a
member of our profession, in whom this elongation of one femur had taken
place to such an extent that he was obliged to wear a very high shoe on
the other, that is, the healthy, limb. And this, which he had adapted
for himself, affords the only remedy for the inequality of limbs. Nor is
the remedy unimportant : for, to say nothing of the unsightly lameness
which it produces, the morbid elongation of the limb is apt to be soon
complicated by one of two serious consequences. Either the patient, in
his endeavors to support himself steadily and upright, will acquire first
the habit, and then the malformation, of talipes of the healthy limb ; or
else, through the habit of always resting on the short, healthy, and
stronger limb, he will have lateral curvature of the spine. Cases of both
these kinds have occurred in Mr. Stanley's practice ; being brought to
him for the remedy, not of the elongated femur, but of the consequent
deformity of the foot or the spine.
A considerable elongation of the lower extremity almost always depends
on the femur being thus affected : another, and very characteristic result
ensues from the same kind of hypertrophy when it occurs in the tibia.
The femur can grow longer without materially altering its shape or
direction, but the tibia is tied by ligaments at its two ends to the fibula ;
so that when it lengthens, unless the fibula should lengthen to the same
extent, it, the tibia, must curve ; in no other way, except by the lengthen-
ing of the ligaments, which, I believe, never happens to any considerable
extent, is elongation of the tibia possible.
Tibiae thus curved are far from rare ; specimens are to be found in
nearly every museum : yet I know of none in which the pathology of the
HTPXBTBOPHT
disease is clearljr shown except one, in the Museuni of St. Bartholomew'a
(Snbeer. A, 46), which is here sketched. Fig. 5.
Id this, the fibula, and the health; tibia of the
opposite limb are preserved with the elongated tibia.
The anterior wall of this tibia, measuring it over its
curve, is more than two inches longer than that of the
health; one : the posterior wall is not quite so long.
In all Buch specimens you may observe a charao-
terlatic form of the curve, and its distinction from
the curvature of rickets. The distinction is esta-
blished by these particulars : the ricketty tibia is
always short; the other is never short, and may
be longer than is natural: in the ricketty one
the articular ends always enlarge very suddenly,
for the shortening is due to the imperfect forma-
L tion of the ends of the shaft ; in the elongated
tibia there is usually oven less contrast of sin
between the shaft and epiphyses than is natural,
because the elongation of the shaft is commonly
attended with some increase of its circumference; .
but, especially, the ricketty tibia is compressed,
usually curved iuwards, its shaft is flattened late-
rally, and its margins are narrow and spinous ;
while, in the elongated tibia, the curve is usually
directed forwards, its margins are broad and round,
its surfaces are convex, and the compression or flat-
tening, if there be any, is from before backwards.
The elongation of the bones in these cases may occur, in different in-
stances, in two ways. In some cases it seems duo to that change in bone
which is analogous to chronic inflammation of soft parts, and which con-
sists in the deposit of the products of inflammation in the interstices of
the osseous tissue, their accumulation therein, and the remodelling of the
bone around them as they accumulate. Such a change appears to have
occurred in the specimen from which the sketch was taken, and would
necessarily give rise, in a growing bone, as it does in soft parts, to en-
largement in every direction, to elongation as well as increase of cir-
cumference.
But, in other cases, the elongation is probably due to the more genuine
hypertrophy which follows the increased flow of blood. When, for
example, a small portion of bone, as in circumscribed necrosis, is actively
diseased, all the adjacent part is more vascular ; hence may arise a
genuine hypertrophy, such as I have shown in hair under similar circum-
stances. Or, when an ulcer of the integuments has long existed in a
young person, the subjacent bone may shore in the increased afllux of
blood, and may enlarge and elongate. Even, it appears, when one bone
OF BONES. 69
18 diseased, another in the same limb may thus be increased in length.
A remarkable instance of this kind has lately been observed by Mr.
Holden, in a yonng man, who, in childhood, had necrosis of the left tibia,
(me of the consequences of which was defective growth of the left leg,
with shortening to the extent of more than an inch. Tet the whole limb
is not shorter than the other; for without any apparent morbid change of
texture, the femur of the same side has gro¥m so as to compensate for
the shortening of the tibia.
An interesting example of similar increased growth of one bone, in
eompensation for the weakness of another, is found sometimes in cases of
ill-repaired fractures or diseases of the tibia. The fibula, at the part
corresponding with the weak portion of the tibia, is in such cases
strengthened sufficiently for the support of the limb. So in a specimen
in the Museum of St. Bartholomew's (Ser. 3, 86), taken from a dog ten
weeks after a piece of the radius was cut out with its periosteum, while
the gap in the radius is filled with only soft tissue, the exactly corre-
sponding portion of the ulna is increased by the formation of new bone
beneath its periosteum.
I must not forget to say, that the interest of these cases of inequality
of the limbs, by lengthening of one of the bones, is increased by com-
parison with another class of cases, in which as great or greater in-
equality of length depends on one limb being anormally short. In
these, the short limb has been the seat of atrophy, through paralysis of
the muscles dependent on some of the very numerous conditions in
which they may be rendered inactive. The complication of the cases,
the talipes, and the curvatures of the spine, depending, as they do, on
the inequality of the length of the limbs, from whatever cause arising,
will be alike in both ; and much care may be needed in diagnosis, to tell
which of the limbs, the long one or the short one, is in error. The best
characters probably are, that when a limb is, through disease or atrophy,
too short, it will be found, in comparison with the other, defective in
circumference as well as in length ; its muscles, partaking of the atrophy,
will be weak and flabby, and all its tissues will bear signs of imperfect
nutrition. If none of these characters be found in the short limb, the
long one may be suspected ; and this suspicion will be confirmed, if
there be found in it the signs of increased nutrition, such as enlarge-
ment, growth of hair, and the rest : or if, in the history of the case,
there be evidence of a disease attended with an excess in the supply of
blood.
Crontinuing to select from the Museum only such examples of hyper-
trophy as may illustrate its general pathology, I pass over many, and
take next, those which display the formation of corns ; a subject which,
while Hunter deemed it worth consideration, we shall not be degraded
by discussing. He made many preparations of corns, to show not oiAy
70 HYPBRTROPHT
the thickening of the cuticle, but the formation of the little sac of fluid,
or bursa, between the thickened cuticle and the subjacent articulation.
His design appears to have been, mainly, to illustrate the different
results of pressure ; to show how that which is from without produces
thickening : that from within, thinning and absorption of parts. He
says, having regard to these specimens, ^' The cuticle admits of being
thickened from pressure in all parts of the body : hence we find that on
the soles of the feet of those who walk much the cuticle becomes very
thick ; also on the hands of laboring men. We find this wherever there
is pressure, as on the elbow, upper part of the little toe, ball of the
great toe, &c. The inmiediate and first cause of this thickening would
appear to be the stimulus of necessity given to the cutis by this pressure,
the effect of which is an increase of the cuticle to defend the cutis under-
neath. Not only the cuticle thickens, but the parts underneath, and a
sacculus is often formed at the root of the great toe, between the cutis
and ligaments of the joint, arising from the same cause, to guard the
ligaments below."*
In another place he says, "When from without, pressure rather sti-
mulates than irritates ; it shall give signs of strength, and produce an
increase of thickening : but, when from within, the same quantity of
pressure will produce waste" [as illustrated in Nos. 120 and 121 in the
Pathological Museum] ; " for the first effect of the pressure from without
is the disposition to thicken, which is rather an operation of strength ;
but if it exceeds the stimulus of thickening, then the pressure becomes
an irritator, and the power appears to give way to it, and absorption of
the parts pressed takes place, so that Nature very readily takes on those
steps which are to get rid of an extraneous body, but appears not only
not ready to let extraneous bodies enter the body, but endeavors to
exclude them by increasing the thickness of the parts."t
It is evident from these passages that Mr. Hunter was aware that
pressure from without might produce atrophy ; though he may appear to
favor the belief, which, I think, is commonly adopted as on his autho-
rity, that the direction of the pressure is that which determines its
result. Really, the result seems to depend more on whether the pres-
sure be occasional or constant. Constant extra-pressure on a part
always appears to produce atrophy and absorption ; occasional pressure
may, and usually does, produce hypertrophy and thickening. All the
thickenings of the cuticle are the consequence of occasional pressure ; as
the pressure of shoes in occasional walking, of tools occasionally used
with the hand, and the like : for it seems a necessary condition for hyper-
trophy, in most parts, that they should enjoy intervals in which tlicir
nutrition may go on actively. But constant pressure, whether from
within or from without, always appears to give rise to unrepaired absorp-
tion : and most museums contain interesting examples of its effects.
• Hunter's Works, vol. i., p. 560. t Ibid., vol. iii., p. 4 CO.
CAUSBD BY PBESSURE. 71
Some yertebrse in the College Museum (121 A), illustrate very well
the results of pressure by aneurisms and tumors. So far as themselves
are concerned, the pressure of the aneurism was from without inwards ;
yet they are atrophied ; not ulcerated, but hollowed out, and remodelled
in adaptation to the shape of the aneurismal sac : their cancellous tissue
is not exposed, but, as in the natural state, is covered by a compfete
thin external layer of compact tissue.
The pressure of a loose mass of bone in the knee-joint (No. 955 in the
same Museum), was from without inwards ; but its result was atrophy,
as shown in the formation of a deep pit at the lower end of the femur,
in which it lay safely and almost tightly lodged.
Again, the effect of constant pressure is shown in the cases in which
one of the lower incisor teeth of a rodent animal has continued its growth
after the loss of the corresponding upper incisor, and, being no longer
worn down by attrition in growing, attains an unnatural length. In
such a case, the extremity of the tooth, turning round so as to form
nearly a complete circle, has come into contact with the side of the
lower Jaw, and (like, as they tell, the Fakir's finger-nails growing through
the^tlllckness of his clenched hand) it has perforated the whole thickness
of the jaw ; the absorption consequent on its pressure making way for
its onward course.
A yet stranger example was taken from the body of a woman in the
dissecting-room of St. Bartholomew's Hospital, and the specimen (Ser.
1, 232) tells all the history that can, of perhaps need, be given. She
had an aperture in the hard palate, and for remedy of its annoyance,
used to wear a bung, or cork, in it. But the constant pressure of so
rough an obturator produced absorption of the edges of the opening,
making it constantly larger, and requiring that the cork should be often
wound-round with tape to fit the widening gap. And thus the remedy
went on increasing the disease, till, of all the palatine portions of the
upper maxillary and palate bones, nothing but their margin or outer
shell remains : the rest is all absorbed. The antrum is on each side
obliterated by the apposition of its walls, its inner wall having probably
been pushed outwards as the plug was enlarged to fit the enlarging
aperture in the palate. Nearly the whole of the vomer also has been
destroyed, and the superior ethmoidal cells are laid open.
Lastly, as an instance in which, in the same part, permanent pressure
product atrophy, and occasional pressure hypertrophy, I may show a
Chinese woman's foot. The bandaging, and constant compression in
early life, produced this diminished growth ; but afterwards, when, with
all the miserable doublings-up and crowding of the toes, the foot was
used in walking, the parts of pressure became the seats of corns.
We may sometimes observe the same contrast after amputations. A
hole may be absorbed in an upper flap where it lies on the end of the
bone, and is subject to the constant pressure of its own weight *, but, m
72 atrophy:
older stumps, the greater occasional pressure on the artificial limb leads
to thickening and hardening of the parts.
These examples, then, may suffice to show, as I have said, that con-
stant pressure on a part produces absorption ; occasional pressure (espe-
cially if combined with friction) produces thickening or hypertrophy;
and that these result whatever be the direction of the pressure. And,
yet, let me add, that Mr. Hunter was not far wrong, — he never was ; for
nearly all pressures from without are occasional and intermittent, and
nearly all pressures from within, arising, as they do, from the growth of
tumors, the enlargement of abscesses, and the like, are constant.
LECTURE V.
atropht: degeneration.
I PROPOSE now to consider the subject of Atrophy; the very contrary
of the hypertrophy which I endeavored to elucidate in the last two
lectures.
By atrophy is commonly implied, not the cessation or total privation
of the formative process in a part, but its deficiency ; and as I limited
hypertrophy to the cases in which an increased power is acquired for a
part by the growth, or by the development, of healthy tissue ; so shall
atrophy be here taken to mean only that process by which a part either
simply wastes and is reduced in size, with little or no change of texture,
or else, gradually and regularly degenerates.
By the terms of this limitation it is implied, that, as there are two
modes of hypertJrophy, the one with growth, the other with development;
so there are two modes of atrophy, the one with simple decrease, the
other with degeneration, of tissue. In both, there is a loss of functional
power in the part; but in one, this loss is due to the deficient quantity,
in the other to the deteriorated quality, of the tissue. But, as in hyper-
trophy the development and the growth of the afiected part usually
concur, so, in atrophy, a part which becomes smaller usually also degene-
rates, and one which degenerates usually becomes smaller. Still, one or
other of these, either the decrease or the degeneration, commonly pre-
vails ; and we shall see reasons why the distinction is very necessary to
be made.
Let me first state, and even at some length, what is to be understood
by degeneration, and how its efiects may be distinguished from those of
disease.
I implied in a former lecture, that the maintenance of a part in its
DEGENBRATIOK. 73
nutrition must not be understood as being the maintenance of an un-
changed state : rather, each part may be said to present a series of
minute progressive changes, slowly effected, and consistent with that
exercise of its functions which is most appropriate to the successive
periods of its existence.
Now, after a certain length of life, these changes accumulate Into a
very noticeable deterioration of all, or nearly all, parts of the body ; and
they suffer a manifest loss of functional power. Thus changed, we say
they are degenerate : these accumulated changes are the signs of decay,
the infirmities of age, the senile atrophy. They are the indications of de-
fective formative power, and often speak more plainly of old age than do
the years a man may have counted ; they testify that the power which
prevailed over the waste of the body in childhood and youth, and main-
tained the balance in vigorous manhood, has now failed : as the tide,
after a flood and a period of rest, turns and ebbs down.
All the expressions usually employed about these changes imply that
they are not regarded as the results of disease : nor should they be ; they
are. or may be, completely normal ; and were it not that the forces
wfai^ are efficient in degeneration are, probably, very different from
those which actuate the formative processes, we might justly call the
degeneration of advanced age another normal method of nutrition. For,
to degenerate and die is as normal as to be developed and live : the
expansion of growth, and the full strength of manhood, are not more
natural than the decay and feebleness of a timely old age ; not more
natural, because not more in accordance with constant laws, as observed
in ordinary conditions. As the development of the whole being, and of
every element of its tissues, is according to certain laws, so is the whole
process regulated, by which all that has life will, as of its own workings,
oease to live. The definition of life that Bichat gave is, in this view, as
untrue as it is illogical. Life is so far from being ^' the sum of the func-
tions that resist death," that it is a constant part of the history of life
that its exercise leads naturally to decay, and through decay to death.
Of the manner in which this decay or degeneration of organisms
ensues we know but little. Till within the last few years the subject of
degenerations was scarcely pursued : and, even of late, the inquiries,
which ought to range over the whole field of living nature, have been
almost exclusively limited to the human body. The study of develop-
ment has always had precedence in the choice of all the best workers in
physiological science. They who have devoted many years of laborious
thought and observation to the study of the changes by which the living
being is developed from rudiment to perfection, have given fewer hours
to the investigation of those by which, from that perfection, it naturally
descends into decay and death. Almost the only essays at a general
illustration of the subject have issued in the ridiculous notion that, as the
body grows old, so it retrogrades into a lower station in the scale of ani-
74 atrophy:
mal creation. The flattened cornea is supposed to degrade the old man
to the level of the fish ; while the ar(ms senilis, by a fancied corre-
spondence with an osseous sclerotic ring, maintainB him in the eminence
of a bird : his dry thick cuticle makes him like the pachydermata ; amd
his shrivelled spleen approximates him to the humility of the moUusL
One can only commend such day-dreams to the modern supporters of the
doctrine of transmutation of species ; and they might, indeed, form an
appropriate supplement to their scheme, if they would maintain that, in
these latter days, our species is destined to degenerate into lower and
yet lower forms, descending through the grades by which, in bygone
times, it ascended to its climax in humanity.
We cannot but wonder at the comparative neglect with which wiser
men than these philosophers have treated a study, so full at once of
importance and of interest as this, of the natural degeneration of the
body. It could not be without interest to watch the changes of the body
as life naturally ebbs ; changes, by which all is undone that the forma-
tive force in development achieved ; by which all that was gathered from
the inorganic world, impressed with life, and fashioned to organic form,
is restored to the masses of dead matter ; to trace how life gives bafik to
death the elements on which it had subsisted ; the progress of that decay
through which, as by a common path, the brutes pass to their annihila-
tion, and man to immortality. Without a knowledge of these things our
science of life is very partial, very incomplete. And the study of them
would not lack that peculiar interest which appertains to inquiries into
final causes. For all the changes of natural decay or degeneration in
living beings indicate this design ; that, being gradual approximations to
the inorganic state of matter, they lead to conditions in which the' ele-
ments of the body, instead of being on a sudden and with violence dis-
persed, may be collected into those lower combinations in which they
may best rejoin the inorganic world ; they are such, that each creature
may be said to die through that series of changes which may best fit it,
after death, to discharge its share in the economy of the world, either by
supplying nutriment to other organisms, or by taking its right part in
the adjustment of the balance held between the organic and the inorganic
masses.
Nor would the student of the design of these degenerations do well
to omit all thought of their adaptation, in our own case, to the highest
purposes of our existence. When, in the progress of the " calm decay"
of age, the outward senses, and all the faculties to which they minister,
grow dim and faint, it may be on purpose that the Spirit may be invigo-
rate and undisturbed in the contemplation of the brightening future ;
that, with daily renewed strength, it may free itself from the encum-
brance of all sensuous things, or may retain only those fragments of
thought or intellectual knowledge which, though gathered upon earth,
yet bear the marks of truth, and being Truth, may mingle with the
DEQENERATION. 75
Truth from Heayen, and form part of those things in which Spirits of
infinite purity and knowledge may be exercised.
Moreover (and this is in the closest relation to my present subject),
the changes of natural degeneration in advanced life have a direct impor-
tance in all pathology ; because they may guide us to the interpretation
of many similar anomalies which, while they occur in earlier life, we are
apt to call diseases, but which are only premature degenerations, and
are to be considered, therefore, as methods of atrophy ; as defects, rather
than as perversions, of the nutritive process ; or as diseases, only in con-
sideration of the time of their occurrence.'*'
The changes that mark the progress of natural decay or degeneration
in old age, and that may, therefore, be regarded as the typical instances
of simply defective nutrition, seem to be these: — 1. Wasting or wither-
ing ; the latter term may imply the usually coincident wasting and dry-
ing which constitute the emaciation of a tissue. 2. Fatty degeneration,
including many of what have been called granular degenerations. 3.
Earthy degeneration, or calcification. 4. Pigmental degeneration. 5.
Thickening of primary membranes.
Of each of these let me cite one or two examples.
Of withering^ or wasting and drying, which is perhaps the commonest
form of atrophy, we have abundant instances in the emaciation of old
ige ; in which, while some parts are removed by complete absorption,
others arc only decreased in size, and lose the succulency of earlier life.
The fatty degeneration in senility is best shown, as a general occur-
rence, in the increasing obesity which some present at the onset of old
age, and in the general fact that there is more fatty matter in all the
tissues, and most evide|)LlJy in the bones, than there is in earlier life ;
while, as local senile fatty degenerations, we find the arcu% senilis, or
fatty degeneration of the cornea, and the accumulating fatty or athero-
matous degenerations of arteries.
The calcareous degeneration is, in old age, displayed in the gradually
increasing proportion of earthy matter in the bones ; in the extension of
ossification to cartilages, which, in all the period of vigor, had retained
their embryonic state ; and in the increasing tendency to earthy deposits
in the arteries, and other parts.
The pigmental degeneration has its best instances in the gradually
accumidating black pigment spotting and streaking the lungs ; in the
slate or ash-color which is commonly seen in the thin mucous membranes
of the stomach and intestines of old persons ; and in the black spotting
* One can here have in view only the cases in which the degeneration affects the whole,
or some considerable part, of an organ ; for it is very probable that some of the degenera-
tions which we see en maste in the organs of the old, or in the scats of premature defect of
nutrition, are the same as occur naturally in the elementary structures of parts, ptevious to
their being absorbed and replaced, as it were, by one particle at a time, in the regular pro-
cess of nutrition.
This bpojt i^ ^4^ ^,^
76 .atrophy:
of the arteries of some animals, in which pigment seems to hold the
place of the fatty degenerations so usual in our own arteries.
Of the thickening of primary membranes we have indications in the
usual thickening of the tubules of the testes, and, I think, of some other
glands, as their function diminishes in old age ; in the opaque white
thickening of the primary or inner membrane of nearly all bloodvessels ;
and in the thickening of the walls of cartilage cells in senile and some
other ossifications. To this, also, we have a strong analogy in the thicken-
ing of the cell-walls of the heart-wood of plants.
These changes, singly or in various combinations, constitute the most
evident degenerations of old age in man. Their combinations give rise
to numerous varieties in their appearance ; such as, e. g.y the increase of
both fatty and earthy matter in old bones ; the dry, withered, and darkly
tinged condition of the epidermis ; the coincident fatty and calcareous
deposits in the arteries ; the thickened walls and fatty contents of the
seminal tubes. But, at present, I need not dwell on these ; nor on the
conditions which determine the occurrence of one rather than another
mode of degeneration ; for these I cannot tell.
Now, if we observe the conditions in which these senile, and therefore
typical, examples of degeneration are imitated in earlier life, they are
such as indicate that the changes are still to be ascribed to a defect, not
to a perversion, of the conditions of nutrition or of the vital forces.
Thus, these changes are all especially apt to occur in a part of which
the functions are abrogated : a motionless limb wastes or becomes fatty
as surely as an old one does. They arc found ensuing when one or more
of the conditions of nutrition are removed, not changed. For example,
a fatty degeneration of part of a heart may eni?ue when, through disease
of a coronary artery, its supply of blood is diminished. They often occur
in parts that fail to attain the development for which they seemed to be
intended. Thus fatty degeneration usually ensues in the cells of unfruitful
Graafian vesicles.* In short, all their history, when we can trace it, is
that of atrophies.
We may, therefore safely hold, that, as the changes to which the several
tissues are naturally prone in old age are certainly the results of defect,
not of perversion, of the nutritive process, so are the corresponding
changes when they happen in earlier life ; although, through their appear-
ing prematurely, they may bear the features of disease.
The distinction between degeneration and disease is essential, though
often it may be obscure. Degeneration, as to its process, is natural,
though it may be premature ; disease is always unnatural : the one has
its origin within, the other without, the body : the one is constant, the
other as various as the external conditions in which it may arise : to the
one we are prone, to the other only liable.
The general diagnostic characters of degenerations are chiefly these : —
• Reinliardt, in TraulHj's Boitrftgc, B. i. p. 145.
DEaENERATION. 77
1. They are such changes as may be observed naturally occurring, in
one or more parts of the body, at the approach of the natural termination
of life, or, if not then beginning, yet then regularly increasing.
2« They are changes in which the new material is of lower chemical
composition, t. e., is less remote from inorganic matter, than that of which
it takes the place. Thus fat is lower than any nitrogenous organic com-
pound, and gelatine lower than albumen, and earthy matter lower than
all these.
3. In structure, the degenerate part is less developed than that of
which it takes the place : it is either more like inorganic matter, or less
idvanced beyond the form of the mere granule or the simplest cell.
Thus, the approach to crystalline form in the earthy matter of bones,
and the crystals in certain old vegetable cells, are characteristic of de-
generation ; and so are the granules of pigment and of many granular
degenerations, and the globules of oil that may replace muscular fibres
or the contents of gland-cells, and the crystals of cholesterine that are
often mingled with the fatty and earthy deposits.
4. In function, the part has less power in its degenerate than in its
natuml state.
5. In its nutrition, it is the seat of less frequent and less active change,
and without capacity of growth or of development.
Such are the characters by which in general we might separate the
processes and results of degeneration from those of disease, and of natural
nutrition. But we must remember always that the process of degeneration
may concur with either of those from which, in its typical examples, it may
be so clearly separated. It may mingle with development ; or, at least,
by a process of degeneration, a part may become adapted to a more de-
veloped condition of the system to which it belongs. So it is in the pro-
cess of ossification. It is usual to speak of cartilage as being developed
into bone, and to regard bone as the more developed and more highly
organized of the two tissues. But I think it is only in a very limited
sense that this mode of expression is just. Professor Owen, in some
admirable remarks'*^ on the cartilaginous state of the endo-skeleton of
Chondropterygian fishes, has said — " I know not why a flexible vascular
animal substance should be supposed to be raised in the histological scale
because it has become impregnated, and, as it were, petrified by the abun-
dant intussusception of earthy salts in its areolar tissue. It is perfectly
intelligible that this accelerated progress to the inorganic state may be
requisite for some special oflfice of such calcified parts in the individual
economy ; but not, therefore, that it is an absolute elevation of such parts
in the series of animal tissues.'* Let me add, that all that one sees of
the life of cartilage, in the narrower survey of the higher mammalia, is
conformable with this view, and would lead us to speak of its change into
bone as a degeneration, rather than a development. The change is effected
• Lectures on Comparative Anatomy, vol. ii. p. 140.
78 atrophy:
not only in the vigor of life, but as constantly, in certain parts, in its
decay ; and, whenever it is effected, the part that has become bone
almost ceases to grow, except by superaddition : the interstitial changes
of normal nutrition are reduced to their lowest stage. Cartilage, too, is
less frequently and less perfectly repaired after injury than bone is ; and
its repair is commonly effected by the production of bone ; yet it is con-
trary to all analogy for a lower tissue to be repaired by the formation of
a higher one. It may be added that the granular, and in some instances
even crystalline, form, in which the earthy matter of bone is deposited,
is inconsistent with the supposition that its animal matter has acquired a
higher development than it had before in the state of cartilage. So far,
therefore, as its position in the series of animal tissues is concerned, bone
should be placed below cartilage ; as a tissue which has degenerated into
a state of less active life, and has acquired characters that approximate
it to the more lowly organized and to the inorganic substances. An osseous
skeleton is, indeed, proper to the most highly developed state of the indi-
vidual, and in this relative view bone appears superior to cartilage : but,
with as much right, in the same view, the atrophied thymus gland, and
the renal capsules almost arrested in their growth, might claim to be
regarded as developments from their foetal state ; for these, also, are
normal parts of the more perfect organism : they are like the degenerate
members of an ennobled society, except in that, in their humiliation, they
augment the common weal.
The points of contact, and even of complete fusion, are yet more nume-
rous between degeneration and disease. In many diseases, probably even
in the whole class of inflammations, a degeneration of the affected tissue
is a constituent part of the morbid process ; and in many cases we must
still doubt whether the changes of texture that we observe are the results
of degeneration or of disease. Among these are the instances of the
simple softening of certain organs, such as the brain and spinal cord, and
the liquefactions of inflammatory exudations in the suppurative process.
If we limit the term degeneration to the changes that imitate the typical
examples of old age, these changes cannot be included under it ; but they
may be, if we consider the conditions in which they occur, and the mere
decrease of power which some of them manifest. The softening of the
brain and spinal cord, for example, occurs in some cases through mere
defect of blood ; in some through mere abrogation of function ; it is often
concurrent with distinct signs of atrophy ; and, as I shall describe in the
next lecture, it is attended with changes that closely imitate those of
fatty degeneration. On the whole, therefore, while admitting the diffi-
culty that must often occur in endeavoring to separate such changes as
these from the effects of disease, or of local death, yet I think we should
do well to classify them imder such a title as that of liquefactive degene-
ration."
The sum of this discussion respecting degenerations is as follows : — We
DBaBNBRATION. 79
observe certain changes naturally ensuing in the tissues during advanced
age, and we ascribe these to defect, not to disorder, of the formative pro-
cess : we notice the same or similar changes in earlier life, and we refer
them to similar defect, and class them as methods of atrophy : we seem
justified in thus regarding them, by the general fact that they often have
the same origin, and are concurrent, with the atrophy which is attended
irith merely defective quantity of tissue ; and lastly, we regard certain
changes of texture, such as some forms of softening of organs, as degene-
rations or atrophies, because, though they are not natural in old age, they
occur in nearly the same conditions, and manifest some of the same cha-
ncters, as the atrophies which imitate those of senility.
Among the degenerations that I have enumerated, only one has been
Tery carefully studied, namely, the fatty degeneration. This deserves a
fall description, first, because of its own great importance in pathology,
for there is scarcely a natural structure or a product of disease in which
it may not occur ; and secondly, for its illustration of the general doc-
trine of defective nutrition, and for guidance in the study of the degene-
rations that are at present less understood. For we may be nearly sure,
that general truths, deduced from examples of fatty degeneration, will
hold equally of the other forms, and especially of the calcareous and pig-
mental ; between which and the fatty degenerations there are so many
obvious features of close resemblance, that I shall content myself, having
enumerated them, with merely referring to the examples of them that
irill be described in future lectures.*
The anatomical character of many examples of fatty degeneration will
be described in the next and in subsequent lectures. Their principal
general feature is, that in the place of the proper substance of an ele-
mental structure, e. g, in the place of the contents or the nucleus of a
cell, or in the very substance of a simple membrane, a blastema, or a
fibre, minute particles or granules are seen, which are recognised as con-
sisting of oily or fatty matter, by their peculiar refraction of light, their
solubility in ether, their aptness to coalesce into larger oil-drops, and,
when they are very abundant, by the greasiness of the whole tissue, its
burning with a bright flame, and its yielding to analysis an imusual
quantity of fatty matter. In examining organs in the state of fatty
degeneration, we may commonly see the progress of the change in the
gradual increase of the fatty particles. Some cells, for example, may
appear quite healthy ; some may deviate from health only in containing
two or three shining, black-bordered, oil-particles ; in others, these are
increased, and a large part of the cell-cavity is filled with minute oil-par-
ticles, or with one or more larger oil-drops ; and in others, the contents
of the cell have given place to a single cluster of oil-drops. In this last
* The index will afford at once a sufficient guide to these examples.
80 FATIT DBaBNBBATION.
case, the degeneration is nearly complete : the transformed cell is called
a '^ granule-cell," or, when, as it often happens, the cell-wall has wasted
and disappeared, it is a '^granule-mass;** and the last stage of degene-
ration is that such masses may break up, their constituent molecules may
dispart, and the tissue which was an aggregate of nucleated cells may
become little more than a mass of molecules or drops of oily matter.
It is probably due in part to such disintegration of degenerate cells,
that, in most organs thus degenerate, abundant fatty matter is found
free, that is, lying in drops not enclosed, among the proper constituents
of the tissue. But this free fat is also derived, in part, from the dege-
neration of intercellular substances, which is usually concurrent with
that ensuing in the cells ; and in some cases (as Virchow has observed
in the liver) it so follows the arrangement of minute blood-vessels that it
may be considered as the residue of a direct deposit or exudation from
them.
In most instances the fatty degeneration affects, first and chiefly, as I
have described it, the contents of cells or tubules, or the proper substance
of membrane or other tissue. And when it thus happens, the nuclei
almost always waste, and either shrivel or disappear after gradually
fading in their outlines. This may be commonly seen in the fatty dege-
neration of the renal and hepatic cells, and of the muscular fibres ; and
it is a fact of some significance, when we remember the constancy and
abundance of nuclei in actively growing parts. But, in certain cases,
as in fatty degeneration of cartilages, the change appears to begin in
the nuclei, which are gradually transformed into granule masses, while
the cell-wall may remain unchanged, or may become thickly walled or
laminated, or may coalesce with the surrounding tissue.
Such a transformation of a nucleus, while it retains its place and
general form, might at once suggest that the fatty matter which collects
in these degenerations is not introduced from without into the cells or
other elements of the tissues ; that it is not placed in them, as it may be
in the parts around them, as a morbid deposit, or exudation from the
bloodvessels ; but rather is one of the products and residues of some
chemical transformation which they undergo when the proper nutritive
changes arc suspended. We might derive the same suggestion from the
similarly degenerate muscular fibres ; in which we may often find the fat
particles arranged in the same manner as the proper constituents of the
fibrils, and looking as if there were a gradual transformation of the
" sarcous elements" into the little oily particles, which, by clustering,
and then by fusion, at length compose the larger oil-drops.
We gain other and better evidence of the fatty matter being derived
from chemical changes in the tissue that is degenerate, from many other
sources. Such changes are exemplified in the production of fatty matters
during the spontaneous decompositions of nitrogenous substances. Many
PATTT BEGENEBATIOK. 81
instances* of this are kno?m, but none are so appropriate as the forma-
tion of adipocere in muscular tissue. Here, as Dr. Quain discovered,
the places of the muscular fibres, bloodvessels, and nerves, are occupied
by fatty matter, which could not have existed in them during life, which
is far too abundant to have been derived from changes in the fatty matter
that they naturally contain, and which, in confused crystals, retains
their natural shape, size, and arrangement. And Dr. Quain has com*
pleted the evidence of the chemical nature of these degenerative changeS|
by an artificial imitation of them. He has shown that the textures of
hearts (and the same is true of other parts), when placed in very dilute
nitric acid, or in diluted spirit, pass into a condition exactly resembling
that of the fatty degeneration which I have been describing, f No fact
could be more apposite to prove that this form of degeneration is an
atrophy ; for we may be very sure that when imitable chemistry prevails
in a part, the forces of life, even those of morbid life, are defective or
suspended in it.
The whole history of fatty degenerations concurs to prove that they
are the result of defect, not of disease, of the nutritive process ; and that
ihej may be therefore classed with the atrophy which we recognise in
merely diminished quantity of formation. Let me point out the chief
features of this history : for even some repetition of the earlier part of
the lecture will be justified by the utility of assigning their right place
in pathology to changes of which (as is the case with all these degenera-
tions) we are every year gathering new and very important illustrations.
I have said that the types or standards of degenerations are the
changes naturally ensuing in old age. Now, accumulations of fat, which
in many parts assume the forms of the fatty degeneration of tissues, are
striking characteristics of old age, and especially of the commencement
of senile infirmities. The results of senile atrophy are not, indeed, the
same in all persons : rather, you find among old people, and you might
almost thus arrange them into two classes, the lean and the fat ; and
these, as you may see them in any asylum for the aged, impersonate the
two kinds of atrophy I have spoken of, as the withering and the fatty
degenerations.
Some people, as they grow old, seem only to wither and dry up;
sharp-featured, shrivelled, spinous old folk, yet withal wiry and tough,
clinging to life, and letting death have them, as it were, by small instal-
ments slowly paid. Such are the " lean and slippered pantaloons ;'* and
their "shrunk shanks'' declare the pervading atrophy.
• Muiy arc coUected by Virchow, in his Archiv., B. i., p. 167 ; and others by Dr. Quain
Mei Chir. Trans., vol. xxxiiL, p. 140, et seq. The facts concerning the formation of sugar
fiom nitrogenous compounds in the liver are of the same kind.
•I" Dr. Qoain has candidly referred to many previous observers by whom similar changes
were recognised ; but the honor of the full proof, and of the right use of it, belongs to him-
self mkme. Respecting the method of the chemical transformations by which the change is
iplished, the best essay is, I think, that of Yirchow (Archiv., B. L, p. 152).
6
82 FATI.T DEGEKEBATION.
Others, women more often than men, as old and as ill-natured as
these, yet make a far different appearance. With these the first sign of
old age is that they grow fat ; and this abides with them till, it may be,
in a last illness sharper than old age, they are robbed even of their fat.
These, too, when old age sets in, become pursy, short-winded, pot-
bellied, pale and flabby ; their skin hangs, not in wrinkles, but in rolls ;
and their voice, instead of rising '^ towards childish treble," becomes
gruff and husky.*
These classes of old people, I repeat, may represent the two ohief
forms of atrophy ; of that with decrease, and that with fatty or other
degeneration, of tissues. In those of the first class you find all the
tissues healthy, hardly altered from the time of vigor. I examined the
muscles of such an one ; a woman, 76 years old, very lean, emaciated,
and shrivelled. The fibres were rather soft, yet nearly as ruddy and as
strongly marked as those of a vigorous man ; her skin, too, was tough
and dry ; her bones, slender indeed, yet hard and clean ; her defect was
a simple defect of quantity, and of moisture.
But in those that grow fat as they grow old, you find, in all the tissues
alike, bulk with imperfect texture ; there is fat laid between, and even
within, the muscular fibres ; fat about and in the fibres of the heart, in
the kidneys, and all the vessels ; their bones are so greasy that no art
can clean them : and they are apt to die through fatty degeneration of
some important part, such as the heart, the minute cerebral bloodvessels,
or the emphysematous lungs. The defect of all these tissues is the
defect of quality.
Now, I do not pretend to account for this great difference in the con-
comitants of the other infirmities of old age in different people. The
explanation probably lies far among the mysteries of the chemical phy-
siology of nutrition, of the formation of fat, and of respiratory excretion ;
and we may hope to find it when we know why, out of the same diet,
and under all the same external conditions, one class of men, even in
health and vigor, store up abundant fat, and another class excrete the
elements of fat. In relation, however, to the present subject, the main
point is, that the similarity of the conditions in which they occur implies
similarity in the essential nature of the two changes, and that the defec-
tive quantity and the defective quality of the tissues are both atrophies.
The same conclusion may be drawn from the frequent coincidence of
the two methods of degeneration in the same part. In the limbs, the
most common form of atrophy from disease is manifested in diminution
of size, together with increase in the fatty matter combined with the
* Mr. Barlow, in some admirably written " General Observations on Fatty Degeneration,"
(Medical Times and Gazette, May 15th, 1852,) has pointed out that the climacteric disease}
described by Sir H. Halford, and the " Decline of the Vital Powers in Old Age," described
by Dr. Marshall Hall, are probably, in great measure, dependent on such fatty degeneration
as these persons extremely exemplify.
FATTY BEGENEBATIOK. • 88
muscles and bones. Such is the condition usually displayed by the
bones and muscles of paralysed limbs ; in the majority of atrophied
stomps after amputation ; and in many other similar cases.
In like manner, the fatty degeneration of a part is commonly seen as
the consequence of the very causes which, in other instances, give rise to
simple wasting or emaciation of the same part. Thus, when the function
of a part is abrogated, from whatever cause, the part may in one person
shrink, in another degenerate into fat. The emaciation of a paralysed
limb is a familiar object : but in some cases the muscles of paralysed
limbs are hardly reduced in size, but are all transformed into fat. In
the College Museum there is a pancreas, with a cancerous tumor pressing
on its duct, and all behind the part obliterated is degenerated into fat ;
and in the Museum of St. Bartholomew's there is also a pancreas, the
duct of which was obliterated ; but in this, the part behind the obstruc-
tion is simply shriyelled, dry, hard, and scarcely lobulated. So, too,
among the bones atrophied in different bed-ridden persons, some are
exceedingly light, small, and dry : others are not small, but very greasy,
fiill of fatty matter. Either of these results, also, or the two mingled in
Tarious proportions, may result from defective supply of blood ; as in the
cases of atrophy of parts of bones after fractures, as described by Mr.
Curling, to which I shall have again to refer. So that from these, and
fit)m many other cases hereafter to be mentioned, we may say generally,
that nearly all the ordinary causes of atrophy may produce, in any part,
in one case reduction of size, in another fatty degeneration, in another a
concurrence of the two.
Much yet remains to be said of this important change : but it will be
more appropriate to the next and other lectures, in which I shall describe
the fatty degenerations of several parts, and of the products of inflam-
mation and other diseases, as well as that remarkable form of the
degeneration which ensues, with the rapidity of an acute disease, in the
proper textures of some inflamed parts. It seems only necessary, in
conclusion, to state that there appears no necessary, or even frequent,
connexion between the fatty degeneration of any organ in particular,
and that general tendency to the formation of fat which constitutes
obesity. No doubt, a person, especially an elderly one, who has a natu-
ral tendency, even when in health, to become corpulent, will, cceteria
paribuSj be more likely to have fatty degeneration, than to have a wast-
ing atrophy, in any organ which may fall into the conditions in which
these changes originate. And, as a general rule, spirit-drinking, and
the excessive use of hydro-carbonous articles of food, while favoring a
general formation of fat, are apt to give rise to special fatty degenera-
tion in the liver, or some other organ. Yet, on the other hand, one
commonly finds the proper elements of the tissues — the heart, the liver,
and the rest— quite healthy in men who are very corpulent. The mus-
cular fibres of the heart, or of the voluntary muscles, may be imbedded
84 ATBOPHT.
in adipose tissne, and jet may be themselyes free from the least degene-
ration. So, also, the hepatic cells may be nearly free from fat within,
though there be much oil around them. Fat accumulated in tissue round
the elements of a part is a very different, probably an essentially diffe-
rent, thing from fat within them ; the one is compatible with perfect
strength, the other is always a sign of loss of power. In the muscles of
some fish, such as the eel, it is hard to get a clear sight of the fibres, the
oily matter around them is so abundant : but the fibres are peculiarly
strong, and, in their own texture, make a striking contrast with the fibres
of a degenerate muscle, in which the fat is, in great part, within.
The same essential distinction between general and local fat-formation,
though they may often coincide, is shown in the fact that the local foi^
mation very often happens in those whose general condition is that (rf
emaciation, as in the phthisical and chloritic.
On the whole, therefore, we must conclude that something much mofe
than a general tendency to form fat, or a general excess of fat in the
blood, is necessary to produce^a local fatty degeneration. The general
conditions are favorable, but not essential, to this form of atrophy.
LECTURE VI.
ATROPHY.
The last lecture was chiefly occupied with a general account of those
changes of texture which are to be regarded as atrophies ; and now,
haying pointed out what affections may bo classed under this term, the
whole subject may be more largely illustrated by particular examples.
First, as to the conditions in which atrophy, whether with decrease or ;
with degeneration, may ensue. Many of them may be most easily ex-
plained as the very contraries of the conditions in which hypertrophy .
originates. Thus, as we have seen that when a part is, within certain ]
limits, over-exercised, it is over-nourished ; so, if a part be used less ^
than is proper, it suffers atrophy. For instance, in the Museum of St» i
Bartholomew's (Ser. 12 ; 57), is the heart of a man fifty years old, who |
died with cancer of the stomach in extreme emaciation. It is extremely « (•
small, and weighed only five ounces four drachms ; whereas, according to \
the estimates of Dr. Glendinning, in a healthy man of the same age the |
heart weighs upwards of nine ounces. But, small as it is, this heart was i
adapted to the work it had to do ; and in this adaptation we have the ^
purpose of its atrophy. For, because of his cancer, the man had less ^
blood, and needed less force of the heart to propel it : so that, in direct .
opposition to what I described as the course of events in hypertrophy, 1
here, as the quantity of blood diminished, and the waste of the heart by :
I ATBOPHY. 85
exercise in propelling it diminished, so the repair of the waste diminished
somewhat more than the waste itself did : and the heart, though less
wasted, became smaller, till it was only large enough for the propulsion
of the scanty supply of blood.
The same may be said of a heart of which there is a drawing in the
aune Museum. It was taken from a woman twenty-two years old, who
died with diabetes. It weighed only five ounces ; yet, doubtless, it was
enoogh for her impoverished supply of blood.
It would be superfluous to describe many instances of atrophy through
defective exercise, or abrogated function of parts. The wasted and de-
generate limbs of the bed-ridden, the shrunken brains of the aged and
the imbecile, the withered ovaries and uteri of many barren women, are
good examples of defective nutrition adapted to defective exercise of
function : and so are the atophied distal parts of nerves whose trunks
have been divided, and the atrophied columns of the spinal cord that
correspond with inactive portions of the brain. The rapid degeneration
and removal of the tissue of the uterus after parturition, and the rapid
disappearances of temporary organs of various kinds, are as striking
examples of atrophy foUoAving the abrogation or completion of office.
To some of these examples I shall again refer.
It is in similar contrast with the history of increased growths, that, as
an excess of the constituents of which a tissue may form itself produces
hypertrophy of that tissue, so may defect of those constituents produce
atrophy. Thus, the quantity of adipose tissue diminishes even below
vhat is natural to the several parts, as often as the fat-making constitu-
ents are deficient in the food, and therefore in the blood. So, the
fbnnation of bones is-defective during deficiency of the supply of bone-
eirtlis ; the mammary glands waste when the materials for the formation
rf milk are imperfectly supplied ; and the whole body wastes in general
defect or poverty of blood.
Again, as I showed instances in which the increased flow of healthy
Hood through a part produced hypertrophy, so are there more numerous
examples of merely defective nutrition in consequence of a diminished
^^ly of blood. Some of the most striking of these were first described
\fj Mr. Curling,* in cases of fractured femora and other bones, showing
unfpbj of that portion which, by the fracture, was cut oS" from the
stffly of blood through the great nutritive or medullary artery. The
coDsequence of the withdrawal of so much of the blood from the upper
cr lower fragment, according to the position of the fracture, is not
death ; for the anastomosis between the vessels of the wall and those of
tke medullary tissue of the bone is enough to support life, though not
eooogh to support vigorous nutrition ; but the frequent consequence of
4e fracture is an atrophy of the part thus deprived of a portion of its
ittdy supply of blood.
* Medico-Chinirg. Trans, vol. xx.
86 ATBOPHY.
Similar instances are seen in the decrease or degeneration of portions
of hearts when single branches of a coronary artery are obstructed ;* in
the wasting of a portion of kidney when a branch of a renal artery is
closed ;t and in local softening of the brain, with obliteration of single
cerebral arteries.];
In all these instances we see that conditions contrary to those ^ving
rise to hypertrophy produce atrophy. But there are many other condi-
tions from which atrophy in a part may ensue ; defects in quantity, or in
the constitution, of the blood ; defective or disturbed nervous ii^uenoe,
as through excessive mental exertion; the disturbances of diBease or
injury, as in inflammations, specific morbid infiltratias, &c. In short,
whatever interferes with or interrupts any of those conditions which I
enumerated as essential to healthy nutrition, may give rise to atrophy,
either general or local. The clinical history of the fatty degeneration
of the heart, so largely illustrated by Dr. Ormerod§ and Dr. Quain,||
may best prove how multiform are the events from which the atrophy of
a single organ may arise.
But besides all the instances in which atrophy of a part may arise as
a secondary process, there are others in which we are so unable to trace
its precedents, that we are tempted to speak of it as primary, or sponta-
neous, in the same sense as we might so call the natural wasting of the
Wolffian bodies, the thymus, and other temporary organs. It is as if an
atrophy of old age, instead of affecting all parts simultaneously, took
place prematurely in one.
Whatever the true explanation may be, most of the parts of tho body
appear to be subject to this seemingly spontaneous atrophy ; and it gene-
rally manifests itself in some form of degeneration. Its most frequent
seats are the heart and arteries, the bones, muscles, liver, and kidnejrs ;
but it occurs also in the pancreas and the salivary glands, and in the
testicle. It is yet more frequent in morbid products, as in the fibrinous
deposits on tho interior of arteries, the exudations of inflammation, and
tumors of every kind.
The contrast between hypertrophy and atrophy is, thus, nearly as
great in the number, as in the kind, of the conditions in which they may
severally arise. And, once more, we may contrast them in regard to
the mode in which the vessels and nerves adapt themselves. As a part
becomes atrophied, its bloodvessels and its nerves are consequently and
proportionally changed. In atrophy of the eye, the optic nerve and
artery diminish ; and, in a case of fatty degeneration of the adductor
muscles of the thigh, in consequence of disease of the hip-joint, I found
• Quain, MedicoChir. Trans. xxxLii. p. 148 ; Virchow, Archiv. iv. p. 387.
"f Simon, Lectures on Pathology, p. 94.
J Kirkes, Med.-Chir. Trans, vol. xxxv.
§ Medical Gazette, 1849.
jl Medico-Chirurgicai Trans., vol. xxxiii. 1850.
ATBOPHT. 87
corresponding atrophy of their nerves. The atrophy of the nerves must
have been, in this case, secondary : the course of events being, inaction
of the muscles in conseqnence of the disease of the joint ; then, atrophy
of them in conseqnence of their inaction ; and, finally, atrophy of the
nerves following that of the muscles.
From these general considerations I proceed to speak particularly of
Atrophy, as it manifests itself in some of the principal organs and tissues
of the body ; — ^and first of the Atrophy of Muscles.
The affection has been well studied in all the three forms of muscular
tissue; namely, in the voluntary muscles, in the heart, and in the
organic or smooth-fibred muscles ; and I will describe it in each of these
in order.
The voluntary muscles exhibit, in different conditions, both the chief
forms of atrophy ; that, namely, with decrease or wasting, and that with
fatty degeneration.
In a wasted muscle, such as one sees, for example, in the limbs of
those who are only emaciated, the fibres may appear almost perfectly
healthy : they are rather paler, indeed, and softer, and more disposed to
be tortuous, than in the natural state ; for muscles are commonly withered
when they are thus reduced in size ; yet their transverse striae, and all
thdr other characteristic features, are well marked.
In the state of fatty degeneration, the whole of a voluntary muscle
may appear pale, bleached, or of some yellowish or tawny hue, soft and
easily torn. But a more frequent appearance is that in which fasciculi
in the healthy state, and others in various degrees of degeneration, lie
in parallel bands, and give the whole muscle a streaky appearance, with
various hues intermediate between the ruddiness of healthy flesh, and the
dull, pale, tawny-yellow, or yellowish-white, of the complete degeneration.
In such a case (and this may appear remarkable) healthy primitive fibres
may lie among those that are degenerated. Of the latter, some, in place
of the transverse striae, present dark very minute dots arranged in trans-
verse lines ; in others, the whole fibre has a dim, pale, granular aspect,
with no definite arrangement of the granules ; in others, little oil-glo-
bules adhere to the interior of the sarcolemma ; and in others, such glo-
bules are collected more abundantly, and to the proportionally greater
exclusion of the proper constituents of the fibres : but the characters of
fatty degeneration are rarely, if ever, so well marked in the fibres of
voluntary muscles as in those of the heart.
In the examination of different examples of fatty degeneration of the
voluntary muscles, you may find much diversity in the tissue between
the fibres and fasciculi. In some instances, the interspaces between the
fasciculi are filled with cellular tissue, both more abundant and tougher
than that in healthy muscle ; so that it may be hard to dissect the fibres
for the microscope. With this there may be no unusual quantity of fat ;
88 ATROPHY OF
but, in other cases, the quantity of fat between the fibres is very great,
and the fibres themselveis may seem empty, or wasted, as if overwhehned
by the fat accumulating around them. In such a case, when the accu-
mulating fat has coalesced with that which before surrounded the whole
muscle, it may be difficult to find where the muscle was ; for the whole
of what belonged to it, after its degeneration, may be gone, and in its
place there may remain only an obscure trace, if any, of fibrous arrange-
ment, dependent on the position of the principal partitions of the new
fatty tissue.
I cannot yet speak positively in explanation of this diversity in the
state of parts between the fibres. But, I think, the increase and tough-
ness of the cellular tissue (when it is not the product of organized inflam-
matory deposit) exist only in atrophied muscles which have had to resist
stretching, after the manner of ligaments ; as, for example, when their
antagonists are not as powerless as themselves. And the increase of
fat seems to be found only when a muscle has been very long atrophied,
and has remained completely at rest ; then, the fibres themselves, after
degenerating, may be removed, and give place to a formation of common
adipose tissue, which collects in every part that they are leaving, just as
it does about shrinking kidneys, some cancers of the breast, old diseased
joints, and other parts similarly circumstanced.
In either case, we must distinguish between these formations of^fat
outside, and those within, the fibres ; the former are in no necessary
connexion with the proper atrophy of the fibres, but generally appear
subsequent to it ; and when they attain their highest degree, they are
not to be regarded as degenerations of the muscular tissue ; for they are
not, in any sense, formed out of it, though they occupy the place from
which it was removed.
The condition in which atrophy of the voluntary muscles most com-
monly ensues is inaction. Whenever muscles lie long inactive, they
either waste or degenerate ; and this whether the inactivity depend on
paralysis through afiection of the nervous centres or fibres, or fixity of
the parts they should move, or on any other cause. The degenerative
process may be so rapid that, in a fortnight, muscles paralysed in hemi-
plegia may present a manifest change of color ; but it is commonly a
much slower process.
The course of events in these cases appears to be, that the want of
exercise of a muscle, whether paralysed or fixed at its ends, makes its
due nutrition impossible ; and the atrophy thus brought about is the
cause of loss of irritability of the muscle, i, e,, of loss of its capacity for
contracting. For the experiments of Dr. John Kcid* show that loss of
contractile power in a paralysed muscle is due, directly, to its imperfect
nutrition, and only indirectly to the loss of connexion with the nervous
• Edin. Monthly Jour, of Med. Science, May, 1841. See, also, M. Brown-Sequard, in the
Gaz. M6dicale, No. 9, 1850.
YOLUKTART MUSCLES. 89
centres. When lie divided the nenres of a frog's hind legs, and left one
limb inactive, but gave the muscles of the other frequent exercise, by
galvanizing the lower end of its divided nerve, he found (to state the
case very briefly) that at the end of two months the exercised muscles
retained their weight and texture, and their capacity of contraction;
whOe the inactive ones (though their irritability, it might be said, had
not been exhausted by exercise), had lost half their bulk, were degenerate
in texture, and had also lost some of their power of contracting. In
other cases, too, he found the loss of proper texture always ensuing in
the inactive state, before the power of contraction was lost.
It is doubtless the same in man. A muscle wnich, by no fault of its
own, but through circumstances external to itself, has been prevented
from acting, soon becomes incapable of acting even when the external
obstacles to action are removed. Hence we may deduce a rule which
ought to be acted on in practice. When a person has had hemiplegia,
one commonly sees that long after the brain has, to all appearance,
recovered its power, or even through all the rest of life, the paralysed
fimbfl remain incapable of action, and as motionless as at the first attack.
Now, it is not likely that this abiding paralysis is the consequence of any
continuing disease of the brain : rather, we must ascribe it to the imper-
fect condition into which the muscles and nerve-fibres have fallen during
their inaction. So long as the state of the brain makes voluntary action
impossible, the cord, nerves, and muscles, are suffering atrophy ; then,
when the brain recovers, they are not in a state to obey its impulses,
because they are degenerate ; and thus, their inaction continuing, they
degenerate more and more, and all remedy becomes impossible. If this
be true. Dr. Reid*s experiments suggest the remedy. When muscles are
paralysed through aflfection of the nervous system, we ought to give them
artificial exercise : they should be ofteS put in action by electricity or
otherwise ; their action, though thus artificial, will insure their nutrition ;
and then, when the nervous system recovers, they may be in a condition
ready to act with it.
You will find this suggestion ingeniously supported by my friend Mr.
W. F. Barlow, in a paper published by him in the Lancet. In one case,
in which I could act upon it, the result was encouraging. A little girl,
about eight years old, had angular curvature and complete loss of volun-
tary movement in the lower extremities. This had existed some weeks,
but as I found she had reflex movements, the legs twitching in a very
disorderly way as often as the soles were touched, I advised that the
limbs should be put in active exercise, for about an hour two or three
times a day, by tickling the feet, or in some similar way. The result
was, that when, several weeks afterwards, the spinal cord recovered, and
she could again direct the effort of the will to the lower limbs, the
recovery of strength was speedy and complete ; more so, I think, than
if, in the paralysed condition, the muscles and nerves had been left to
90 ATROPHY OF
the progress of the atrophy. A similar paralysis, about two years later,
occurred again, and was similarly recovered from.'
The hindered action of muscles, though the most frequent, is not the
only condition from which their atrophy may ensue. They waste, toge-
ther with all the rest of the body, in most emaciating diseases ; as, for
example, in phthisis : and they may degenerate into fat, in concert with
other tissues, in a generally defective nutrition.
But, besides the general atrophies of muscles, a similar affection occurs
sometimes as a primary or spontaneous affection of one or more muscles.
We find sometimes one of the muscles of an extremity, or of the back,
thoroughly atrophied, while the others are healthy ; and no account can
be given of its failure.
It is not very imfrequent to find a portion of the lower and posterior
part of the recti abdominis muscles in a state of fatty degeneration.
Bokitansky'*' briefly refers to a spontaneous fatty degeneration of the
muscles of the calf attended with extreme pain : and Mr. Mayof has
recorded two cases of apparently spontaneous atrophy of the muscles of
the shoulder, in which, in a few weeks after severe pain, but no other
sign of acute inflammation, all the muscles about the shoulder became
simply, but exceedingly, atrophied.
We name these spontaneous atrophies, and it may be that the defective
nutrition is the first event in the abnormal chain ; but, I think, we shall
hereafter find that, in most of them, the degeneration is a part of some
inflammatory process ; for, as I shall have to describe in future lectures^
there is no tissue in which it is more evident than in the muscles, that a
degeneration of the proper elements of an inflamed part is associated
with the more obvious effects of inflammation.
Atrophy of the muscular stAstance of the heart, may, like that of
which I have just been speaking, appear in either wasting or degeneration,
or in a combination of the two. Of the former, I mentioned examples in
the beginning of the lecture, in the heart of a cancerous man, 50 years
old, which weighed only five ounces four drachms ; and that of a diabetic
woman, 25 years old, which weighed only five ounces one drachm. Both
these had deviated from the general rule of enlargement of the heart
with advancing years, in adaptation to the diminished quantity of blood,
and the general diminution of the body.
In these cases there is a uniform decrease of the heart : its cavities
become small, and its walls proportionally thin ; and the fat on its exte-
rior diminishes or is changed into a succulent, ocdematous tissue. In
other instances the cavities are dilated, without proportionate thickening,
or, it may be, even with thinning of their walls. This probably, occurs,
chiefly in cases of such increased obstacle to the circulation as might, in
• Pathol. Anat., B. 2, S. 348.
t Outlines of Human Pathology, 1836, p. 117.
THB HEABT. 91
other persons, or in other conditions, engender hypertrophy of the heart.
Or, the dilatation may be the consequence of wasting in a heart that was
once large and strong.
Bat, an atrophy of the heart much more important than any oC these,
is that which consists in fatty degeneration.
Extreme instances of fatty degeneration of the heart have been long
known. The whole, or the greater part of the heart in such cases, may
seem reduced to fat ; the degenerate tissue having coalesced with that
which lies on its surface, and the degeneration being accompanied by
thinning and softening of the walls.
In like manner, the cases have been well known and described for
which Dr. Quain proposes the name of ^' fatty growth," to distinguish
them firom the ^^ fatty degenerations" of the heart. In these, the adipose
tissue accumulates in unusual quantity on those parts of the exterior of
the heart in which it naturally exists, and is found, though often ema-
ciated and very soft, even in the thinnest people ; viz., along its trans-
verse furrow, the furrows in which the coronary vessels run, and others.
From these positions, the fat dipping more and more deeply may nearly
displace the fibres, and may lead to a secondary degeneration of them :
but, commonly, the heart's fibres are themselves healthy, even when they
lie completely imbedded in the overgrown fat.
But these conditions, and their combinations, are too well known to
need that I should describe them, or refer particularly to any specimens
of them, except to a sheep's heart, which is in the College Museum (No.
1529), and which shows, in an extreme degree, a method of the growth
of fat which is rarely imitated, in even a trivial measure, in the human
subject. It exhibits a great accumulation of fat on its surface, and its
walls are thin ; but the greater parts of the cavities of the ventricles and
of the left auricle are occupied by large lobulated growths of suet-like fat.
The weight of the fat here added to the heart is 25 ounces, and it is said
that there was also a large accumulation of fat about the kidneys. But
no other history of the case is extant than that the sheep was inactive,
and had dyspnoea on exertion.
These cases of extreme fatty growth, or of extreme degeneration, of
the heart are much rarer than those of which I have now to speak.
The most common form of fatty degeneration is that in which you find,
on opening the heart, that its tissue is in some degree paler and softer
than in the natural state, and lacks that robust firmness which belongs
to the vigorous heart. But what is most characteristic is, that you may
see, especially just under the endocardium, spots, small blotches, or lines,
like undulating or zigzag transverse bands, of pale, tawny, bufi", or ochre-
yellow hue, thick-set, so as to give, at a distant view, a mottled appear-
ance. These manifestly depend not on any deposit among the fasciculi,
but on some change of their tissue. For, at their borders, you find these
spots gradually shaded-off, and merging into the healthy color of the
92 ATROPHY 01*
heart ; and when you examine portions of such spots with the microscopei
you never fail to find the fatty degeneration of the fibre.
The yellow spotting, or transverse marking of the heart, may exist in
the walls of all its cavities at once, or may be found in a much greater
degree in one than in the others. It may exist in all parts of the thick-
ness of the walls, or may be chiefly evident beneath the endocardium and
pericardium. It is far less common in the auricles than in the ventricles;
and when it exists simultaneously in all parts it is less advanced in the
auricles. It is more common in the left ventricle than in the right ; and
in the left ventricle it is commonly most advanced on the smooth upper
part of the septimi, and in the two large prominent fleshy columns.
Indeed, it may exist in these columns alone ; and when, in such a case,
the rest of the heart remains strong, may account for the occasional
occurrence of rupture of the columns.
These yellow spottings of the heart, produced by degeneration of scat-
tered portions of its fibres, are, as I have said, the most evident, as well
as the most frequent, indications of its degenerative atrophy. But a
similar aficction may exist in a worse form, though it be less manifest:
worse, because the degeneration is more extensive and more uniform ;
and less manifest, because it is less distinctly visible to the naked eye,
and must be recognised by the touch rather than by the unaided sight.
The whole heart feels soft, doughy, inelastic, unresisting ; it may be
moulded and doubled up like a heart beginning to decompose long after
death : it seems never to have been in the state of rigor mortis. These
conditions are more manifest when a section is made through the wall of
the left ventricle. Then, if the wall be only partly cut through, the rest
of it may be very easily torn, as if with separation of fibres that only
stick together ; and the cut surface of the wall looks, as it were, lobulated
and granular, almost like a piece of soft conglomerate gland, an appear-
ance which is yet more striking when observed with a simple lens of about
half an inch focus. In color, the heart has not on its surface, much less
on its section, the full ruddy brown of healthy heart, a color approaching
that of the strong voluntary muscle ; but is, for the most part, of a duller,
dirtier, lighter brown, in some parts gradually blending with irregular
marks or blotches of a paler fawn, or dead-leaf-color.
These appearances of the degenerate heart may be variously mingled ;
and they may be variously associated with overgrowths of the external
fat, or with previous hypertrophy or other changes of structure in the
heart. But, however much the appearances of the affection may be
obscured, the general characters of softness, paleness, mottled color, and
friability, will be suflScient, if not always to prove, yet always to excite
suspicion, that the fatty degeneration of the heart exists : and, if only
suspicion is excited, the microscopic examination may be always decisive.
The chief microscopic appearances are deUneated in the adjoining sketch.
When a portion of the heart's walls, especially if they are very soft,
taa HBABi. 98
ia dissected in the ordiiury way, vitb needles, for the microscope, the
fibres are broken into short pieces, some twice, some five or ax times, as
long as the; are hroad. The broken ends of these short pieces are nsually
iqoared ; but some are roimd, or irregular, or cloven, and broken off lower
down. The pieces are almost always completely separated, baring no ap-
pearance of eren cohering at their sides, and they lie scattered disorderly.
In whichever f<nin the degeneration is ezuniDed, yon may find that,
in some pieces, the transverse striae are still well seen and undisturbed,
q>pearisg quite as in health. In more, they are interrnpted or ob-
scured by dark dots, or by glistening particles with shady, black mar-
gins, like minute oil-partioles scattered without order in the fibres.
Where such particles are few, they appear to lie especially, or only,
in contact with the [interior of the sarcolemma; but, where more
nmnerons, they appear to occupy every part of the fibre, leaving the
transverse striae discernible only at its margins, or even completely
obscuring or replacing them, and making the fibre look like a gland-tube
filled with dark granules and larger glistening dark-edged fat-particles.
"Where these particles are very numerous in a fibre, they appear also
generally larger, and more generally glistening and black-edged, like
larger oil-particles.
There may be no oil-drops floating about; no fat-cells; *Bcarce]y even
any of the minute particles, which are seen in the fibres, may appear out
of them ; the field of the microscope may be perfectly clean. In these
minor respects, however, many differences exist ; though I think it may
be stated that the degeneration is very rarely, if ever, accompanied by
any morbid product deposited between the fibres ; whatever fatty matter
may appear between them, is only such as has escaped from them.
As a general rule, the palest parts of the heart are most advanced in
■ J. HmenUr fibre* of the healthr human heaiL
B. Fatty degenBiation of the fibres of the hDmui heiit; b, eaily iCage ; 1^, more ad-
C. The nine, yet mote advanced, all magnified 400 times. Fiom Dt. Quain's platei;
Ifed. Chir. Tism. vol xxxiiL pL 3.
94 ATROPHY OV
the disease ; but even in microscopic portions some pieces of fibres appear
hardly changed, while those all round them are completely granular.
I alluded, in the last lecture, to the defective condition of the nuclei of
degenerate elemental structures. This is peculiarly well shown in the
degenerate fibres of the heart. When those of a healthy heart are placed
in diluted acetic acid, they display a longitudinal series of nuclei, at
nearly equal distances apart, and usually lying in the middle of the pre-
senting surface of the fibre. Such nuclei are, so far as I know, peculiar
to the heart-fibres. They are large, reddish-yellow, like blood-globules,
especially when the heart is very robust : they are elongated, oval, or
nearly quadrilateral ; and at each of their ends one almost always sees
tapering groups of small, isolated, yellowish granules, like particles sepa-
rated from them, and gradually withering. But in the degenerate fibre,
when the change is least advanced, the outlines of the nucleus look dim,
and it loses its color : when the change has made further progress, the
nucleus cannot be seen at all, though its former place may be indicated
by some of the narrow group of granules ; and in a yet later stage, when
the sarcolemma appears nearly full of fatty particles, all trace is lost
alike of the nucleus and of the granules.
I have spoken of fatty degeneration of the heart at this great length,
both because there is no better example for illustration of the general
pathology of such affections, and because it is extremely important that
this condition of the heart should be recognised after death, even when no
suspicion could be entertained of it during life. For it often introdaces
unexpected dangers into the ordinary practice of surgery : it is, I believe,
not rarely the cause of sudden death after operations ; it is one of the
conditions in which chloroform should be administered with more than
ordinary caution. They who labor under ft may be fit for all the ordi-
nary events of calm and quiet life, but they are unable to resist the storm
of a sickness, an accident, or an operation. And let it not be said that
one learns little in learning too late the existence of an incurable
disease; for very often the death that has come from such a disease
has been ascribed to a wrong cause, and has spoiled confidence in good
men and their good measures. Nor does the caution seem unnecessary
that, serious as the efiects of the disease are, the change of structure may
escape any but a very careful and practised examiner. For, often, the
change is hardly manifest to the eye, though while it affects the whole
heart, it may have destroyed life.*
Atrophy of the organic or smooth-fibred muscles doubtless occurs as
• When the lecture was delivered, in 1847, 1 related some cases of sudden death from
this affection ; and expressed the hope that its whole clinical history would be traced by
Dr. Ormerod, who helped nie very much in investigating its morbid anatomy. The hope
has been fulfilled far beyond my expectation by both him and Dr. R. Quain, who was, at
the same time, actively occupied with a similar course of inquiry. I may therefore refer
the reader to their essays, in the Medical Gazette for 1849, vol. ii.; and in the Medico-
Chirurgical Transactions, vol. xxxiii. : essays, valuable alike for the importance of their facts,
and for the thoroughly scientific spirit in which they are conceived.
THB B0KE8. 96
a Bimple decrease of them in /the thinning of the *coats of the intestines,
stomach, and other hollow organs, which is sometimes associated with ge-
neral emaciation, or with diminished function : but the change has not been
earefolly stndied. Of the fatty degeneration of this muscular tissue
examples are described in the muscular coats of the arteries,* which par-
take in the corresponding change, or atheromatous affection, of their thick-
ened internal coats ; in the coats of the urinary bladder ;t and in the
vterofl.^ In the latter organ the change has peculiar interest ; taking
place, as it does, quickly after the fulfilment of office in parturition ; affect-
ing all the muscular fibro-cells which, during gestation, had been deve-
loped to their perfection ; and preceding their absorption and replace
ment by new-formed fibro-cells, like those which existed in the young and
miimpregnated uterus. The series of changes thus traced by Kilian tell
a complete lustory of nutrition, in the succession of deyelopment and
growth to perfection, of discharge of function, consequent degeneration,
absorption, and replacement by new structures that, in their progress,
pass through the same phases as their predecessors. The production of
fat in the uterine tissue confirms also the probability which I have
already mentioned (p. 50), that fat is one of the usual results of the
ehfimi<»d change which takes place in muscular action, and is, in this rela-
tion, a substance, like the kreatine, which is also found in the uterine
tissue after birth,§ intermediate and transitional between the proper
constituents of the tissues and the oxidised materials of excretions. It
may be added, that the whole substance of the uterus and its membranes
partakes of the degenerative change, and that the removal of the old
tissues and the formation of new ones is so total, that, as it has been justly
said, a person has a now uterus after each delivery. But the peculiarity
of the case is only in that the change is accomplished quickly, manifestly,
and simultaneously in a large mass of tissue : in the same sense, though
at unknown times, men have often new hearts, new glands, and new
brains.
In the bones we may probably consider that a calcareous degeneration
occurs as a method of atrophy, in addition to those just described in the
muscles : for to such a degeneration we may ascribe the increased pro-
portion of bone-earths in the skeletons of aged persons. The augmenta-
tion of earthy constituents is not attended with increased strength of the
* Rokitansky, Pathol. Anat., ii. p. 543 ; KoUiker, Zeitschr. iHr wissensch. Zoologie, i, p. 81.
t Mr. Hancock, as quoted by Mr. Barlow, Med. Times and Gazette, May 15, 1852. — The
change of which I spoke, in this lecture, as a kind of fatty degeneration of the bladder in
old people, was not proved to be degeneration of the muscular fibres : neither, I think, has
this been yet proved, though it is highly probable, in the muscular coat of the gall-bladder.
X Koliiker, 1. c. p. 73. Kilian, in Henle und Pfeufer's Zeitschr. fur rat Medicin, vols. viii.
and ix.
S Siegmund, in the Warzborg Yerhandlungen, B. iii. H. 1.
96 ATBOPHT OF
bones: rather, they become, in old persons, thin-walled, and more
easily broken ; the change being commonly associated with both wasting
and fatty degeneration, and the whole tissue being rarified. It is through
this general want of compactness in their construction that old bones are
weak : for, as Dr Stark's analyses show very well, the strength of bones
depends more on their compactness than on the proportion of their con-
stituents.
I am not aware that any analyses of diseased or other bones have
shown a calcareous degeneration of them, except in old age : but its fre-
quent occurrence is highly probable. The other modes of atrophy may
be more fully illustrated in the two forms already often referred to.
The simple wasting of a bone is a common change. Examples have been
already adduced in connexion with the subject of unequal length of the
limbs (p. 69), and with that of the effects of pressure (p. 71), as well as
in relation to the general history of atrophies. Among many specimenfl
in the College Museum, the most striking is the skeleton of an hydroce-
phalic patient from the collection of Mr. Listen (No. 8489). It is the
more remarkable, because while all the bones of the larunk and limbs
are reduced by atrophy, to exceeding thinness and lightness, the bones of
the cranium are as exceedingly enlarged in adaptation to the enormous
volimie of their contents.
Another interesting specimen is a skull (No. 8) fitted up by Hunter to
show the movements of the edentulous lower jaw, as he has described
them in his "Natural History of the Teeth." It shows the atrophy not
only of the alveolar margins, but of every part of the jaws, and even of
their palatine parts, and those of the palate bones, which are quite thin
and transparent.
A rare specimen of atrophy of the lower jaw is shown in a case of com-
plete osseous anchylosis of both temporo-maxillary articulations, from
Mr. Howship's Museum (No. 966). Similar atrophy of bone in its
extreme state is illustrated by an example of anchylosis of the knee (No.
384), from the case described by Mr. Thurnam.* Considerable apertures
are formed in the wasted walls of the femur and tibia, and they were
covered in by the periosteum alone : the whole thickness of these portions
of the walls having been removed in the progress of the atrophy.
In the Museum of St. Bartholomew's is a specimen in which simple
atrophy of the femora led to such fracture as, being effected by a slight
force, is called spontaneous. The atrophy of these bones occurred coin-
cidently with extreme emaciation of all the other parts, as well as of the
skeleton ; an emaciation which was to be ascribed, I believe, more to
starvation than to anything else. The shafts of the femora are exceed-
ingly small, and their walls are so thin, that, although their texture
appears healthy, they could not resist the force of the muscles acting on
the articular ends. They broke: and the result shows a remarkable
* Medical Gazette, vol. xziii p. 119.
THB BONBS. 97
example of the capacity for repair of iojuries even while the process of
Ofdinary nutrition seems almost suspended : for the fractures were firmly
reunited.
I might greatly multiply examples of such simple wasting atrophy of
Ixmes ; but let this suffice, that I may speak now of fatty degeneration
of the bones. .
I have already said that it is common, in many atrophied bones, to
find an excess of fatty matter ; I referred to old bones laden with fat as
examples of a form of senile atrophy ; and sometimes, in cases of dis-
eased joints, the form of atrophy assumed by the disused bones is that
not merely of exceeding thinness of the walls and wasting of the can-
oelli, but of an accumulation of soft fat filling every interstice and
maintaining the size of the bone. But it is now to be added, that the
bones, like other organs, are liable to a fatty degeneration, which, be-
cause of the obscurity of its origin, we must be content to call sponta-
neous; and this fatty degeneration of the bones is the disease which
most English writers have described as Mollities Ossium.
The Museum of the College has a remarkably rich collection of speci-
mens of this disease : a collection embracing specimens from nearly all
the cases with whose histories we are most familiar.
Well-marked examples of the fatty degeneration are shown in No.
400. These are two femora fractured by a slight force, and, in their
dried state, light, very greasy, mahogany-brown, and so soft that you
may crush many parts of them with the fingers. Their excess of fat is
evident ; but no more of their history is known than that they came from
an elderly, if not an old, man, — an Archbishop of Canterbury.
In No. 398 is a section of a himierus, affected, as many other bones
of the same person were, with extreme fatty degeneration ; and the
Catalogue contains, with its description, a reprint of an essay, by Mr.
Hunter, which escaped even the careful research of the editor of his
works, Mr. Palmer. His essay is entitled, '^ Observations on the Case
of Mollities Ossium described,'' &c., by Mr. Goodwin, in the London
Medical Journal.'*' It was communicated in a letter to Dr. Simmons,
the editor of that journal, and I will quote one passage, to show both
what was the original appearance of the bones, and how completely Mr.
Hunter's description confirms the opinion that this mollities ossium was
really a fatty degeneration of the bones. He says, speaking of this
humerus, ^' The component parts of the bone were totally altered, the
structure being very different from other bones, and wholly composed of
a new substance, resembling a species of fatty tumor, and giving the
appearance of a spongy bone, deprived of its earth, and soaked in soft
fat"
Nothing can better express the character of the change, or its simi-
• Vol. vi., 1785.
7
^ ATBOPHT OF
larity to the fatty degenerations of other organs, in which we find the
proper substance of the part gradually changed for fat, and the whole
tissue spoiled, while the size and outer fo^n of the part remain iinal*
tered.
The same characters are shown in the often-quoted case by Mr. How-
ship, of which specimens are preseryed in Nos. 401-2-3. The last of
these specimens shows what remained of the upper part of a femur after
boiling ; scarce anything besides a great quantity of white crystaUine
fatty matter.
It is the same with a femur (No. 403 B) presented to the Mosenm by
Mr. Tamplin, in the examination of which I first obtained, with tiie
microscope, the conviction of the nature of the change which constitates
what we call mollities ossium. This has the same characters as the
specimens already shown, and the medulla of the bone had the bright
yellow, pink, and deep crimson hues, which are so striking in many
instances of the disease. But the constituents of this apparently peon*
liar material were, free oil in great quantity; crystal of margarine,
free, or enclosed in fat-cells ; a few fat-cells full of oil as in health, but
many more, empty, collapsed, and rolled-up in strange and deceptive
forms. The pink and crimson colors were owing to the bright tints of a
part of the oil-globules, and of the nuclei and granules in the collapsed
fat-cells ; and there was no appearance whatever of an excess of blood
in the bone, or any of its contents.
From this examination, therefore, as well as from all the other facts,
I concur entirely in Mr. Curling's opinion respecting this disease.* A
specimen (No. 403 A) from the case on which he chiefly founded his
opinion, and which he has very accurately described, closely resembles
those I have referred to. He proposes the name " Eccentric Atrophy
of Bone'' to express one of the principal characters of the disease ; and
I would have adopted it, as preferable to "Osteoporosis," under which I
think Rokitansky would include these cases, but that it seems desirable
to class this afiection with others to which it bears the closest analogy,
by giving the same generic name in the designation, fatty degeneration
of bones.
The cases to which I have now referred include the principal examples
of the disease observed and recorded in England under the name of
mollities ossium ; and to these, I think, may be added the case described
by Mr. Solly,t for the appearances presented by the femur (No. 403 C)
are strikingly similar to those in the specimens already referred to, and
the material filling its medullary cavity contained abundant fatty
matter.
You might ask, then, what is the real mollities ossium ? or is there
such a disease difierent from what these specimens show ? I could not
from my own observations answer such a question ; for I have never seen
* Medico-Chiiurgical Transactions, vol. xx. f Ibid. vol. zxvii.
THE BONES.
m spedmen wUch appeared to fulfil in any degree the general notion of
mollities osaimn, as a disease consisting in the removal of the earthy
matter of bone, and the redaction of any part of the skeleton to its car-
tOaginoos base. I do not doubt the accuracy of what others have
irritten of such an affection : but I am sure, that the cases I have cited
are not simple softenings of bone, but fatty degenerations ; and that
those cases must be very different to which Rokitansky refers under the
names of, Osteomalacia, Malakosteon, Enochenerweichung, and Bachi-
tismus adultorum. He gives, as a characteristic of the disease, that it
affiBcts the bones of the trunk, or a part of them, much more often, and
more severely, than the bones of the extremities, and occurs especially
after child-bed. Now, in the cases which I have endeavored to illustrate,
the extremities, not the trunk, are the chief seats of the disease ; and
there is no evidence of the fatty degeneration occurring more often after
ddivery than in any other period or condition of life. So that, on the
whole, I think we may consider there are two diseases included under
the name of mollities ossium ; namely, the fatty degeneration which
these specimens show, and which seems to be the more frequent in Eng-
land ; and the simpler softening of bone, or rickets of the adult, to
which Rokitansky's description alludes, and in which the bones are flexi-
ble rather than brittle, and appear reduced to their cartilaginous state.
This affection seems to be more frequent than the fatty degeneration in
Grermany and France: and I think the only probable, well-recorded
instance of its occurrence in England, is that related by Mr. Dalrymple,*
Dr. Bence Jones,t and Dr. Macintyre.^
I feel, however, that there is still much doubt respecting the relations
of these affections ; they, are, perhaps, more nearly allied than, at first
sight, they may seem ; and I think some clue to their alliance may be
obtained from the relation which they both have to the rickets of the
young subject. The relation is best shown in the bones of the skull,
and is illustrated by specimens in the College Museum (Nos. 392 to
396, and 2857 to 2860) ; but I need not now dwell on it while wishing
to give only a general account of the atrophies of bone.§
I can scarcely doubt that ftiture inquiries will ascertain that, in every
tissue, changes such as these which I have described in muscle and in
bone are the results of simply defective nutrition. But I have neither
knowledge nor space for more than a few additional instances. Among
these, the degenerations of bloodvessels may be cited. The blood-
vessels of an atrophied part, I have already said, decrease in adaptation
* Dablin Jonmal of Ked. Science, vol iL, 1846.
t Philos. Traxi&, 1848. % Medico-Chir. Trans., toI. zxxiiL
$ I haye minutely described the specimens here referred to, as well as the later changes
which the bones midergo, in the Pathological Catalogue of the College Museum, toL u. p.
22, and toI. t. p. 7.
100 ATBOPHT OF
to the part : they become less, till thej can carry no more blood than is
just enough to meet the diminished requirements of nutrition : and this
they do, not by such muscular contraction as adapts them to a temporary
decrease of function in a part, but (if one may so speak) by a diminishing
growth. Moreover, when a part degenerates, its bloodvessels are likely
to degenerate in the same manner. There are, I think, instances in
which fatty degenerations of bloodvessels have occurred in consequence
of similar change in the part that they supply. But the more interest^
ing examples are those of primary degeneration of the bloodvessels.
This has been long known in the atheromatous disease, as it was called,
of the larger arteries ; the true nature of which, as a fatty and calca-
reous degeneration of the inner, and, consecutively, of the middlci
arterial coat, was discovered by Mr. Gulliver.'*' The descriptions of this
affection by him and by Rokitansky have left nothing unsaid that is yet
known; but the observations are each year becoming more numerous
and interesting of similar changes .in the minutest bloodvessels. Suoh
changes are especially observable in the minutest cerebral vessels ; and
their importance, in relation to apoplexy, of which they seem to be the
most frequent precedent, as well as for the general Ulustration of the
minute changes on which the defective nutrition of organs may dep^d, .
will justify, I hope, my repeating the description which I wrote from the
first instances in which they were observed, and has since, I think, been
sufficiently confirmed.f
In the least degrees of this affection, the only apparent change of
structure is, that minute, shining, black-edged particles, like molecules
of oil,t are thinly and irregularly scattered beneath the outer surface of
the small bloodvessels of the brain. Such a change may be seen in the
vessels of portions of the brain that appear quite healthy, as well in the
capillaries as in branches of both arteries and veins of all sizes, firom
l-150th of an inch in diameter, to those of smallest dimension.
As the disease makes progress, the oil-particles may increase in num-
ber till the whole extent of the affected vessels is thick-set with them, and
the natural structures, even if not quite wasted, can hardly be discerned.
While their nimiber thus increases, there is, also, usually, a considerable
increase of the size of many of the oil-particles, and they may be seen of
every size, from an immeasurable minuteness to the diameter of l-2000th
of an inch. In other places one sees, instead of this increase of scattered
• Medico-Chirurg. Trans., vol. xxvi. p. 86. "f Medical Gazette, vol. xlv.
{ Dr. Jenner (Med. Times and Gaz., Jan. 31, 1852) has shown that these appearances of
oil-particles are very closely imitated by equally minute xmrticles similarly deposited, bat
which are proved to be calcareous by their solubility in hydrochloric acid. I think it very
probable that what I have here described as fiitty or oily maner may often be, at least in
part, calcareous : we may reasonably expect this affection of the small vessels to be exactly
analogous to the conmfion fatty and calcareous degeneration of the larger arteries, although
there is no generality of coincidence between them. I have also seen a pigmental degene-
ration of small cerebral arteries very similar to the fatty one described above.
THB BLOODYBSSELS. 101
cil-paiticles, or together mth it, groups or clusters of similar minute
ptrticles, which are conglomerated, sometimes in regular oval or round
masseB, like large granule-cells, but more often in irregular masses qr
patches, in the wall of a great part of the circumference of a bloodvessel.
In a single fortunately selected specimen, one may see, in different
branches of a vessel, all these degrees or states of the degeneration ; the
lees and the more thickly scattered minute oil-particles, the clusters of
such particles in various sizes and shapes, and the larger particles like
drops of on.
When the degeneration has made much progress, changes in the struc-
ture, and, not rarely, changes in the shape also, of the affected blood-
vesselfl may be observed. The chief change of structure appears to
consist in a gradual wasting of the more developed proper structures of
the vessels ; growing fainter in, apparently, the same proportion as the
disease makes progress, the various nuclei or fibres are at length alto-
gether lost, and bloodvessels of even l-150th of an inch in diameter
appear like tubes of homogeneous pellucid membrane, thick-set with the
fatty particles. The structures of the vessels are not merely obscured
by the abnormal deposits ; they waste and totally disappear.
The changes of shape which the vessels may at the same time undergo
are various. Very commonly, the outer layer of the wall is lifted up by
one or more clusters of oil-particles, and the outline of the vessel appears
uneven, as if it were tuberous or knotted. Sometimes the outer or cel-
lular coat of the vessels is for some distance raised far from the middle
coat, as if it were inflated, and the space between them contains nume-
rous particles of oil ; (but, perhaps, this raising up of the outer coat is
often produced by water being imbibed while preparing the specimen for
examination.) Sometimes (but, I think, only in vessels of less than
l-500th of an inch in diameter), partial enlargements, like aneurismal
dilatations or pouches of their walls, are foimd.
The vessels most liable to this disease are, I think, the arteries of
about l-300th of an inch in diameter ; but it exists, generally, at the
same time, in the veins of the same or of less size. As a general rule
(judging from the specimens hitherto examined), the disease decreases in
nearly die same proportion as the size of the vessels, and the smallest
capillaries are least, if at all, affected. But there are many exceptions
to this rule ; and it is not rare to find vessels of from l-2000th to l-3000th
of an inch in diameter, having parts of their walls nearly covered with
the abnormal deposits.
The principal and first seat of the deposits is, in arteries, in the more
or less developed muscular or transversely fibrous coat ; in veins, it is in
the corresponding layer, immediately within their external fibro-celluliar
nucleated coat : in vessels, whether arteries or veins, whose walls consist
of only a simple pellucid membrane bearing nuclei, the substance of this
membrane is the first seat of the deposits. In some cases, the outer
103
ATBOFBT OT
fibro-oelhilar co&t of both arteries and veina appears to coatun abimdant
bttj matter. Bat it ia seldom that, in so adTaoeed stage of the affne-
tion, an; of the sevent coats of a bloodvessel can be asd^ed as its diief
seat ; for evoi in large fonr-coated arteries thej wholly waste, and their
remains appear united in a single pellndd layer, of which the whole
ducknesa may be occnpied by the deposit
The figures represent some of the most usual ^pearances of the d^fr-
neration.
The cases in which these changes were first observed were cerebral
apoplexies in which the hemorrhage appeared certainly due to rupture of
the wasted and degenerate bloodvessels. The probability of such an
event is evident ; as it is, also, that the less sudden effect of this condition
of the vessels is likely to be a gradual degeneration of the parts of the
brain which they supply. The relation between organs and their blood-
vessels must in this respect be mutual ; in the same measure, though not
in the same way, as atrophy of an organ, whether wasting or degener^
tive, induces a corresponding atrophy of its bloodvessels, so will the
* Fig. 7. An arterf, of I-300ib of an inch in diametei, and m bnuicb given Trom it, &om
a Boflenetl corpus striBtum. Numeroui oil-particlei of various lizea are scattered in the
mnKuIar coat, iraces of the tissue of which appear in obscure trantvene matk*.
Fig. S. From the same part, a vein t-600th of an inch in diameter, with bntoches IrOdl
l-1200th to l-1800lb, and poniona of capillaiies. Scattered oil-particles, and groups like
brdien irregular gninule<:ellg, are seen in the homogeneous pellucid walls ofallthe vessels.
Fig. 9. A vessel of t.600lh of an inch in diameter, and another of MBOOth, with a bmnch
of 1.3000th of an inch. Groups and scattered oit'parttcle* bm thkk^el in Iba simple, pel.
lucid, membranous walls.
THB NSBVOUS TISSUES. 108
imperfection of degenerate Teasels lead to atrophy of the part in which
they are distributed.
I suppose that the minute bloodyessels of many other parts might be
often found thus d^enerate, if we could examine them as easily as we
can those of the brain; but I am not aware that any have been so
described except those of the eye, in the case of aretu BenHii^ to which
I shall presently refer, and those of the lungs and placenta. In the
lungs, Dittrich"^ has traced affections of the arteries which, he says, the
account I have given above exactly fits, and the consequences of which,
in pulmonary apoplexy, correspond with the cerebral apoplexies due to
rupture of the small bloodvessds of the brain.
Many facts of exceediug interest are known concerning the degenera-
tions of nervous tissues, but, as yet, they are rather fri^gments than a
continuous history.
First, in relation to the causes of degeneration, two are chiefly known ;
namely, defect of blood, and arrested function. Gases of softening of
the brain have been long recognised as the consequences of ligature, or
obstructive disease, of the carotid or other large arteries ; but they have
received a new interest from Dr. Earkes's discoveryf of their frequency
in consequence of the obstruction of healthy cerebral arteries by masses
of fibrine carried into them, after being dislodged from the valves of the
left side of the heart, or from some part of the arterial system. In these
cases, the extent of softening nearly corresponds with the range in which
the branches of the obstructed artery are distributed ; for, beyond the
circle of Willis, the anastomosis among the cerebral arteries, like that
among the cardiac, is not sufficient to carry a full supply of blood into a
part from which the main stream is hindered, though generally enough
to prevent the complete death or sloughing of the part.
Of the atrophy following diminished or abrogated function of nervous
parts I have already mentioned examples in the shrinking of the brain
in old people, in the wasting of the nerves of paralysed or fixed muscles,
and in that of the optic nerve and tract in cases of blindness. To these
may be added the cases observed by Dr. Waller ;X ^^^ ^^ discovered
that when a nerve is divided, its distal part, t. e., the portion between
the place of division and the place of distribution, the portion in which
the nerve-office can be no longer exercised always suffers atrophy, wasting
and degenerating. The same atrophy ensues in the whole length of any
spinal nerve whose root is divided ; and in any system of nerves through
which, after injury of the spinal cord, reflex actions cannot be excited.
The change, in divided nerves, begins at the distal extremities of the
* Ueber den Laenoecshen Lungen-infarktus. Erlangen, 1850.
t Med.-Chir. Trans., vol. xxxv.
X Philoa. Trans., 1850, Part 2 ; and more fully in the London Journal of Medicine, July
1852.
104 ATROPHT OF THB NBRVOUS TISSUES.
nerve-fibreSy and graduallj extends upwards in the branches and trunk
of the nerve ; but is repaired if the ^divided portions of the nerve be
allowed to reunite. I need not say how great interest these facts have
in relation to the anatomy and physiology of the nervous system ; but it
is equalled by those related by Dr. Turck,* which may be used for ascer-
taining the functions of the several columns of the spinal cord, and thdr
relations to the different parts of the brain, in the same manner as, by
those of Dr. Waller, knowledge may be gained of the course and distri-
bution, and of the centripetal or centrifugal office, of the several nerves.
The main fact discovered *by Dr. Turck is, that after diseases of parts of
the brain or spinal cord there gradually ensues a softening, as by atrophy,
of those tracts or columns of the cerebro-spinal axis through which, in
health, impressions were habitually conveyed from the diseased part;
The same general truth is illustrated by both these series of observations ;
namely, that nerve-fibres through which,' from whatever cause, nerve-
force can be no longer exercised, are gradually atrophied. The atrophy
took place very quickly in the frogs that were the subjects of Dr.
Waller's experiments : commencing in young frogs, during the summer,
in from three to five days, and being completed in from twenty to thir^
days. But, in the human subject, the process, reckoned by the observa-
tions of Turck, and those in which I have examined nerves atrophied in
paralysed muscles, is much slower. Changes in the spinal cord are not,
he says, discernible in less than half a year after the apoplexy or other
affection of the brain of which they are the consequence.
The changes in the nerve-fibres thus atrophied are minutely described
by Dr. Waller. At fir||, transverse lines appear in the intratubular
substance, indicating its loss of continuity ; then it appears as if divided
into roimd or oblong coagulated masses, as if its two component mate-
rials were mingled ; then these are converted into black granules, resist-
ing the action of acids and alkalies ; and, finally, these granules are
slowly and imperfectly eliminated.
In the atrophies of the brain and spinal cord, whether from obstructed
circulation or from hindered function, the chief changes that are observed
are, the liquefaction or softening of the whole substance, the breaking-
up of the nerve-fibres, and the production of abundant granule-cells or
masses, and free-floating granules. The exact nature of the change on
which the softening of the substance depends is not yet known ; neither
can we be sure of the origin of the granule-cells. They are very like
those commonly formed in the granular or fatty degeneration of various
cells of both normal and morbid origin : but, produced as they are in
parts of the brain and cord in which no cell-structures naturally exist
(for they may be as abundant in the white substance as in the gray), we
have yet, I believe, to trace the source and method of their formation.
* Ueber secand&re Erkrankung einzelner ROckenmarkstrange. Wien, 1851.
ABGU8 8BNILI8. 105
Their likeness to the granule-cells of recognised fatty degenerations
might be thought sufficient to justify the arrangement of the softenings
of nerve-eubstance irith the rest of that great division of atrophies : but
the concurrence of so peculiar a softening of texture^ and the siigilar
examples of softening or liquefaction, concurrent with the formation of
granule-cells, which are observed in numerous morbid growths, incline
me to suggest that, for the present, it will be better to speak of these
changes as liquefactive degenerations.
The last example of atrophy of which I will speak is that which is
manifested in the arcus senilis, — the dim grayish-white arches or ellipse
seen near the borders of the cornea in so many old persons. Its nature,
as a true fatty degeneration, consisting in the accumulation of minute
oil-drops in the proper tissue of the cornea, was discovered and is fully
described by Mr. Canton.'*' By his and others'f investigations, it haa
also acquired a larger interest, in being found the frequent concomitant
and sign of more widely extended degenerations that are not within sight
during life. Thus, it is commonly associated with fatty or calcareous
degeneration of the ophthalmic artery ; with fatty degeneration of the
muscles of the eyeball ; and, especially in old persons, with fatty dege-
neration of the heart and many other organs. In short, the arcus senilis
seems to be, on the whole, the best indication that has been yet found
of proneness to an extensive or general fatty degeneration of the tissues.
It is not, indeed, an infallible sign thereof; for there are cases in which
it exists with clear evidences of vigor in the nutrition of the rest of the
body ; and there are others in which its early occurrence is due to defec-
tive nutrition consequent on purely local causes, such as inflammatory
affections of the choroid, or other parts of the eye : but, allowing for
these exceptions, it appears to be the surest, as well as the most visible,
sign and measure of those primary degenerations which it has been the
chief object of the last two lectures to describe. J
* ObservatioiiB on the arcus senilis, in the Lancet, 1850 and 1851.
t Especially Brs. Quain, Williams, and Virchow (Archiv, B. iv. p. 288).
;|; The degenerations of organs not described in the lectures may be studied by the follow-
ing references: —
Arteries, Testicles, Lungs, and Liver : Gulliver, in Med.-Chir. Trans., xxvL p. 86.
Liver : Bowman, in Lancet, 1841-2, vol. i. p. 5G0.
Kidney: Johnson, in Med.-Chir. Trans^ xzix. p. i. ; with Appendix in xxx. p. 182;
Simon, in Med.-Chir. Trans., xxx. p. 141; Virchow, in his Archiv, B. iv. p. 264, et seq.;
and Gairdner, Pathology of the Kidney, Edinb. 1848.
Colorless blood-cells, various Epithelial cells, Cartilage-corpuscles, Nerve-cells : Virchow,
in his Archiv, i. p. 144.
Lungs : Rainey, in Med.-Chir. Trans., vol. xxxi. p. 297. ^
Placenta: Barnes, in Med.-Chir. Trans., xxxi v. p. 183.
Placenta, Decidna, and other tissues of the Uterus, as well as the Muscular : Ealian, as
quoted at p. 131.
Cartilage : Redfem, " Anormal Nutrition in the Articular Cartilages," 1850 ; and Virchow,
in his Archiv, B. iv. p. 289.
106 GBNBBAL CONSIDERATIONS OH THB BBPAIB AND
LECTURE VIL
OBNERAL CONSIDERATIONS ON THB REPAIR AND REPRODUCTION OF
INJURED AND LOST PARTS.
Among the general considerations that may be suggested by the pre-
ceding lectures, none, perhaps, is more worthy of earnest thought, than
that of the capacity of adaptation to the variety of their circumstances,
which is displayed by the several parts of the body. Each part may be
said to be conformed, in its first construction, to a certain standard of
measure, weight, and power, by which standard it is adjusted to the
other parts of the whole organism. The first perfection of the economy
is in the justness with which its several parts are thus balanced in their
powers ; and the mutual adaptation thus established is continued, in
ordinary life, by the nutrition of each part being regulated according to
a law of direct proportion to the quantity of work that each discharges.
But when the external conditions of life vary, and require, for the main*
tenance of health, varying amounts of function to be discharged by one
or more parts; and, still more, when disease disturbs the functional rela-
tions of any part to the rest ; then each part displays a capacity of
adaptation to the new conditions in which it is placed : each can assume
a less or greater size and weight ; each can acquire a less or more power-
ful tissue ; each can thus rise above, or descend below, its standard of
power.
This capacity of adaptation is shown in a yet more remarkable manner
in the recovery of parts from the effects of injuries and diseases. It is
surely only because it is so familiar, that we think lightly, if at all, of
the fact that living bodies are capable of repairing the effects of injury,
and that in this capacity they prove themselves adapted for events of
which it is not certain whether they will ever occur to them or not.
The exact fitness of every part of a living body for its present office, not
as an independent agent, but as one whose work must be done in due
proportion with many others concurring in operation with it, is a very
marvellous thing : but it seems much more so, that in the embryo, each
of these parts was made fit for offices and relations that were then
Numerous calcareous degenerations : Dusseau, Het Beenweefsel en Yerbeeningen, Axna-
terdam, 1850.
Pigmental degenerations : YirchoWf in his Archiv, B. i.
The chief general histories of degenerations are by Rokitansky, Patliol. Anat. ; C. J. B.
Williams, Principles of Medicine ; and Yirchow, in the places cited above, and in his Archiv,
B. iv. p. 394.
A remarkable series of instances of fatty degeneration of voluntary muscles has been
lately communicated to the Medico-Chirurgical Society by Dr. Meryon, and will be pub-
lished, I believe, in the 35th volume of the Transactions.
The degenerations of products of disease will be described in future lectures.
BBPEODUCTIOK OF IlfJlTEED AND LOST PARTS. 107
fittore : and yet more nuuTellons than all it seems, that each of them
shonld 8lill have capacity for action in events that are not only fntore,
but uncertain ; that are indeed possible, yet are in only so low a degree
probable, that if ever they happen they will be called accidents.
Let us have always in mind this adaptation of the living body to future
probabilities, while we consider the physiology of repair. If it be fairly
weired, every part of the process of repair will be an argument of
divine design ; and such an argument as cannot be impugned by the sus-
picion that the events among which each living thing is cast have deter-
mined its adaptation to them : for all the adaptations here noted prove
capacities for things future, and only not improbable.
And let us also keep in view how the reparative processes may illus-
trate the laws of ordinary nutrition ; and especially observe that they
furnish evidence of the nature of the formative force exercised in the
complete organism. I mentioned in a former lecture (p. 52) that, in
many instances of repair and reproduction, the formation of the new
replacing structures cannot be ascribed to an assimilative force, or to the
development of tissue-germs derived from the injured or lost parts. The
completeness of repair after injury, and the extent to which it is some-
times accomplished, become thus most strikmg evidences of the principle
that the formative force, and those that co-operate with it, are, in the
completed organism, the same and continuous with those which actuated
the formation of the original tissues, in the development of the germ and
embryo. There is in every considerable process of repair a remaking of
a part : and the new materials assume the specific form and composition
of the part that they replace, through the operation of no other, or
otherwise directed, force, than that through which that part was first
made. For, in all grave injuries and diseases, the parts that might
aerve as models for the repairing materials to be assimilated to, or as
tissue-germs to develope new structures, are lost or spoiled ; yet the
effects of such injury and disease are recovered from, and the right spe-
cific form and composition are regained. In all such cases, the repro-
duced parts are formed, not according to any present model, but accord-
ing to the appropriate specific form ; and often with a more strikingly
evident design towards that form as an end or purpose, than we can dis-
cern in the natural construction of the body.
Moreover, it will be observed in the instances of repair of injury, even
more plainly than in the maintenance of the body in the successive ordi-
nary stages of its life, that the law of formation is at each period of life
the same : that every part is formed after the same method as was ob-
served in the corresponding part of the parent at the same period of life.
Thus, when, in an adult animal, a part is reproduced after injury or
removal, it is made in conformity, not with that condition which was
proper to it when it was first formed, or in its infantile life, but with that
which is proper according to the time of life in which it is reproduced ;
108 GBKKRAL OONSIDKBATIOHS OH THB BBPAIB AHV
proper, because like that which the similar part had, at the same time of
life, in members of former generations. In the reproduction of the foot
or the tail of the lizard, they grow, as it were, at once into the foil
dimensions proper to the part, according to the age of the individoal.
Spallanzani expressly mentions this : — that when a leg is cat &om a fall-
grown salamander, the new leg and foot are developed, aa &r as form
and structure are concerned, just as those of the larva were ; bat as to
sise, they from the beginning grow and are developed to the proper
dimensions of the adult. The power, therefore, by which this reprodno-
tion is accomplished, would seem to be, not the mere revival of one which,
after perfecting the body, had lapsed into a dormant state, bnt the self-
same power which, before the removal of the limb, was occupied in its
m^tenance by the continual mutation of its particles, and is now en-
gaged, ^vith more energy, in the reconstruction of the whole.
The ability to repair the damages sustained by injury, and to reproduce
lost parts, appears to belong, in some measure, to all bodies that have
definite form and construction. It is not an exclusive property of living
beings ; for oven crystals will repair themselves when, after pieces have
been broken from them, they are placed in the aame conditions in which
they were first formed.
The diagram represents a series of casts made from a crystal with
which I imitated the experiments of Jordan.* A. large piece was broken
off an octohedral crystal of alum (A). Before the fracture it was per>
feet in its form, except at one small pit on its surface, where it had what
(writing of animal physiology) might be called a congenital defect. Thus
broken (B) it was placed again in the solution in which it had been formed,
and after a few days its injury was so far repaired as it appears in the
figure C. The whole crystal had increased, but the increase on its
broken surface was proportionally so much greater than on any other,
that the perfect octohedral form was nearly regained. The little con-
genital defect, also, was completely healed. In a few days more the
whole crystal would have been as if it had suffered no injury.
I know not what amount of mutual illustration, if any, the repair of
crystals and of living bodies may afford ; but, in any case, we may trace
• Mallei's AichiT, 1842, p. 46.
BBPBOBUOTION OF INJUBBB AND LjOST PABT8. 109
here Bomething like an umversal property of bodies that are naturally
and orderly conBtmcted : all, in favorable circnmatances, can repair at
least some of the damages to which they are liable from the violence of
external forces.
But, to speak only of the repair and reproduction that occur in the
several orders of the animal kingdom : among these they exist in singu-
larly different degrees, and in such as can be only partially included in
rules or general expressions. The general statement sometimes made,
ihst the reparative power in each species bears an. inverse ratio to its
positioirin the scale of animal life, is certainly not proved; and many
instances are contrary to it: such as the great reparative power possessed
by the Triton ancL other lizards, and the apparently complete absence of
it in the perfect insects. Rather, the general rule which we may expect
to find true, and for which there is already much evidence, may be that
the reparative power bears an inverse proportion to the amount of power
consumed in the development and growth of the individual, and in its
maintenance in the perfect state.
Our ideas of the consumption of power in the organization of matter,
are, perhaps unavoidably, very vague: yet are there facts enough to
prove that the power which can be exercised in a germ is limited, so that
the capacity of assuming the specific organic form cannot be communi-
cated to an indefinite quantity of matter ; and there are also enough to
justify the expression, that the power, thus limited, is in some measure
consumed, 1st, in the development of every new structure, and, 2dly, in
a less measure, in the growth and maintenance of those already formed.
Thus, first, it appears constantly true, that the reparative power is
greater in all parts of the young than in those of the older individuals
of all species. Even when we compare individuals that have all attained
their highest development and growth, this rule seems to be true. We
know it from general observations of the results of similar injuries and
diseases in persons of different ages : numerous as the exceptions may
be, the general rule seems true. . And it is yet more evidently proved in
the case of some lower animals. Spallanzani mentions it in regard to
the reproduction of the tail of the tadpole. The quickness with which
the work of reproduction is both begim and perfected was always, in his
experiments, in an inverse ratio to the age. He says the same for the
reproduction of the legs of salamanders, and it is only in the young,
among frogs and toads, that any reproduction of the limbs will take
place. So, too, in experiments on the repair of fractures, the union of
tendons and the like, in the mammalia, one may see abundant evidence
that the vigor and celerity of the process are in an inverse proportion to
the animal's age. There is, indeed, some reason to believe, that in the
very early period of embryonic life, a true reproduction of parts of
limbs may take place even in the human species. Not to speak of the
possibility that supernumerary members may be formed in consequence
110 OESTBBAi. C0N8IDBEATI0N8 OV THB BBPAIB AHD
of accidental fission of the budding limbs of the embryo, there are cases
in which fingers are found on tha stumps of arms in such circumstances
as justify the belief, that after a limb had been accidentally amputated
in the uterus, these had been produced on its remaining portion.*
All these facts agree well with the belief that the formative power is
gradually diminished in the acts of organizing matter for the mainte-
nance of the body ; and the difference between the completeness of
repair in children and that in adults appears so much greater than the
difference in adults of different ages, that it is probable the formatave
power « more diminished by growth than by mere maintenance:
But, secondly, it seems that the capacity for the repair or reprodui>-
tion of injured parts is much more diminished by deyelopment, than by
growth or maintenance of the body ; i. e.y much more by those transf(n^
mations of parts by which they become fitted for higher offices, than by
the multiplication or maintenance of those that are already perfect in
their kind and function. In other words, to improve a part requires
more, and more perfect, formative power, than to increase it does.
This, as a general principle, is exemplified in many instances. In the
greater part of congenital malformations we find arrest of development,
but no hindrance of growth ; as a heart, in which a septum fails to be
developed, yet grows to its full bulk. If tadpoles be excluded from
due light and heat, their development wiU be much retarded, but their
growth will be less checked : in other words, the conditions of nutrition
which are enough for growth are not sufficient for development. When
a part is, without disease, unduly supplied with blood, it may grow be-
yond its normal size, but it is never developed beyond its normal struc-
ture : that which is sufficient for increase of growth, is not enough for
an advance in development. Again, in the miscalled cultivation and
improvement of flowers, growth is increased, but development is hin-
dered ; and an excess of colored leaves is formed, instead of the due
number of male and female organs. In an old ulcer or a sinus, cells
may be continually reproduced, maintaining or even increasing the
granulations, yet they will not develope themselves in cellular tissue and
cuticle for the healing of the part. And so, lastly, even when repair
and reproduction have gone far towards their ultimate achievement, that
which takes a longer time, and oftener fails, is the improvement, the
perfecting, of the new material, by its final development. This is
observed in all cases of reproduced limbs, and even in ordinary scars.
These facts (and there are many others like them) seem to justify the
expression that, not only more favorable conditions, but also a larger
amount of organizing force, are expended in development than in
growth, or maintenance; and that the reparative power bears an in-
verse ratio to the amount of force already expended in these processes.
* See a paper by Dr. Simpson, in the London and Edinburgh Monthly Journal, January,
1848.
BSPEODVOTIOV OF INJUBBD AND LOST PARTS. Ill
If it be SO, we might expect that in each species, in its perfect state, the
reparative power might be measured by the degree of likeness between
the embryonic and the perfect f^rm, structure, and composition.
There are many apparent exceptions to such a rule, especially in the
Asterise, which, though constructed through manifold metamorphoses,
have great capacity of restoring detached rays; yet it is consistent
with such a rule that the highest amount of reparative power exists in
those lowest polypes in which the materials of the germ-mass are least
transformed, but are multiplied, and, as it were, grouped into the shape
of their bodies. In the Hydra viridis, and Hydra fusca, it seems lite-
rally true that any minute portion derived from the germ-mass, may,
after being separated from the perfect body, reproduce the perfect form.
This is the general truth of the numerous experiments performed on
Hydr» by Trembley, Boesel, and others. They have been so often
quoted, that I need not do more than mention the greatest instances of
reproductive power that they showed.
Trembley cut an Hydra into four pieces : each became a perfect Hydra ;
and, while they were growing, he cut each of these four into two or three.
These fractions of the quarters being on their way to become perfect, he
again divided these, and thus he went on, till from the one hydra he
obtained fifty. All these became perfect ; he kept many of them for
more than two years, and they multiplied by their natural gemmation
just as much as others that had never been divided. Again, he cut
similar polypes longitudinally, and in an hour or less each half had rolled
itself, and seamed up its cut edses, so as to be a perfect Hydra. He
BpUt them into four" he quartered them ; he cut them into « many
pieces as he could ; and nearly every piece became a perfect Hydra.
He slit one into seven pieces, leaving them all connected by the tail, and
the Hydra became seven-headed, and he saw all the heads eating at the
same time. He cut off the seven heads, and, hydra-like, they sprang
forth again. And even the fabulist dared not invent such a prodigy as
the naturalist now saw. The heads of the Lernaean Hydra perished after
excision : the heads of this Hydra grew for themselves bodies, and multi-
plied with as much vigor as their parent trunk.
Now, these instances may suffice to show not only the great capacity
of reproduction in the lowest polypes, but, also, that in them the process
of reproduction after injury confounds itself with that of their natural
generation by gemmation, or, as it probably more rarely happens, by
spontaneous fission. We cannot discern a distinction between them ; and
there are facts which seem to prove the identity of the power which ope-
rates in both. Thus, in both alike, the formative power is limited accord-
ing to the specific characters of the Hydra : immense as the power of
increase is which may be brought into action by the mutilations of the
Hydra, yet that power cannot be made to produce an Hydra of much
more than ordinary size, or to raise one above its ordinary specific cha-
112 GBNBBAL OONSIDBBATIONS ON THB BBPAIB AHD
racters. And, again, the identity of the power is shown in this, that the
natural act of gemmation retards that of reproduction after injury.
Trembley particularly observes, that when an Hydra, from which the
head and tentacula had been cut off, gemmated, the reproduction of the
tentacula was retarded soon after the gemmule appeared.
Many other species manifest this coincidence of the power of propa-
gating by gemmation of fission, and of producing large portions of the
body, and even of reconstructing, from fragments, the whole body.
Among them, as chief examples, are the Actiniae, which after bisection
form two perfect individuals ; and the Holothuriae, which, as Sir J. 0.
Dalyell has observed, when hurt or handled, will eject all their viscera,
leaving their body a mere empty sac, and yet in three or four months
will have all their viscera regenerated. And to these may be added,
from among the Anellata, the young Nereids, and those species of Naisi
on which Bonnet, Spallanzani, and others, made their experiments;
experiments of which the climax seemed to be achieved when a Nais was
cut by M. Lyonnet into thirty or forty separate pieces, and there were
produced from those fragments as many perfect individuals.
Among the instances of greatest capacity of repair, some observed by
Sir J. G. Dalyell'*' seem to illustrate, in a remarkable manner, the general
laws of the reparative processes in even the higher animals ; and especially
the gradual improvement of the repairing part, by which, at length, the
effects of injury may be quite annulled.
In the Hydra Tuba, the species of which he traced that marvellous
development into Medusae, he found that when cut in halves, each half
may regain the perfect form ; but this perfect form is regained only very
slowly, and, as it were, by a gradual improvement of parts that are at
first ill-formed. The sketch, copied from his plate, shows the succession
Fig. 11.
of forms'marking these stages of improvement in the stump, or attached
part of an Hydra Tuba (A), from which the distal half with the tentacula
was cut off.
Through these forms, commencing at B, into which the attached half
* Rare and Remarkable Animals of Scotland, vol. i.
BBPBODUOTIOK OF IKJUBBD AND LOST PARTS. 118
rig. 12.
of A was first changed, the perfect state of a Hydra was at length
reached ; as at C. The fact may possibly be explained (as he suggests)
by the mutilation having disturbed the progress of the Hydra in its de-
relopment of young Medusae; for the experiment was made in March,
nearly at the time when the series of changes should have commenced.
But, if I may venture not to accept the suggestion of so admirable an
observer, I should suspect rather that this is aft instance of gradual reco-
very of perfection, such as we see more generally in the repair of injuries
and diseases in the higher anunals.
He has noticed something of the same kind, and more definite in the
Tubularia indivisa ; one of his experiments on which is here illustrated.
A fine specimen was cut near its root,
and after the natural fall of its head, the
smnmit of its stem was cloven. An im-
perfect head was first produced, at right
angles to the stem, from one portion of
the cleft (A) ; after its fall, another and
more nearly perfect one was regenerated,
and, as it grew, improved yet more (B).
A third appeared, and then a fourth was
yet more nearly perfect, though the stem
was thick, and the tentacula imperfect.
The deft was almost healed ; and now a
fifth head was formed, quite perfect (G);
and after it, as perfectly, a sixth and a
seventh head. All these were produced
in fifteen months.
The lower half of this specimen had
been cut off four months after the sepa-
ration of the stem. Its upper end bore,
first, an abortive head ; then, secondly,
one which advanced further in develop-
ment ; a third, much better ; and then, in succession, other four, which
were all well formed.
The upper portion of this lower half of the stem now showing signs of
decay, a portion was cut from its lowest part, and further manifested the
reproductive power of the stem ; for three heads were produced from the
upper end of the piece cut off, and four from the lower end of the upper
piece which had seemed to be decaying. In 550 days this specimen had
grown twenty-two heads.
Now, I cannot but think that we have, in these instances of gradual
recovery from the effects of injury, a type of that gradual return to the
perfect form and composition which is noticed in the higher animals.
Our theory of the process of nutrition leads us to believe that, in the con-
8
B
114 GBKBBAL C0NSIDEBATI0N8 ON THB BBPAIB AHD
Btant mutation of particles in nutrition, those elements of the blood, or of
any structure, that have been altered by disease, in due time degenerate
or die, and are cast off or absorbed ; and that those which next suc-
ceed to them partake, through the assimilative force^ of the same morbid
character ; but that, every time of renewal, the new particles approach
a step nearer to the perfect state. Thus, as it were, each generation of
new particles is more near^ perfect, till all the effects of the injury or the
disease are quite obliterated. Surely, in the gradual recovery of per-
fection by these polypes, we have an apt illustration of the theory ; one
which almost proves its justice.
The power of reconstructing a whole and perfect body, by the develop-
ment of a fragment, is probably limited to the species that can propagate
by spontaneous fission or gemmation, or that increase their size, as some
of the Anellata do, by the successive addition of rings that are developed
after the manner of gemmules from those that precede them. Where
this power is not possessed, there, whatever be the position of the species
in the animal scale, the reparative power appears to be limited to the
reproduction of the lost members ; such as legs, claws, a part of the body,
the head, an eye, the tail, and the like. Within this limit, the rule seems
again to hold good, that the amount of reparative power is in an inverse
ratio to that of the development, or change of structure and mode of life,
through which the animal has passed in its attainment of perfection, or
on its way thitherward.
Here, however, even more than in the former cases, we need not per-
haps more experiments, but experiments on a larger number of species.
It appears generally true, that the species whose development to the per-
fect state is comparatively simple and direct, have great reparative powers;
while many, at least of those in which the development is with such great
changes of shape, structure, and mode of life, as may be called meta-
morphosis, retain in their perfect state scarcely any power for the repair
of losses. Yet we want more instances of this ; and especially, it were
to be wished that we had the results of experiments upon the lowest ani-
mals that pass through such metamorphoses ; e. g. on the Hydra tuba,
not only in its Hydra state, but in all the changes that succeed, till it
attains its complete medusal form.
In the absence of such evidence as experiments of this kind might
furnish, the best examples of the rule are furnished by the experiments
of Mr. Newport. They show that amotig the insects, the reparative
power, in the complete state, is limited to the orders in which that state is
attained by a comparatively simple and direct course of development ; as
the Myriapoda and Phasmidae, and some of the Orthoptera. These can
reproduce their antennsD, and their legs, after removal or mutilation ; but
their power of reproduction diminishes as their development increases.
Even in the Myriapoda, whose highest development scarcely carries
BEPBODnOTIQK OF INJUBED AND LOST PABT& 116
their external fonn beyond that of the larvae of the more perfect insects,
saeh reparatiTe power apparently ceases, when, after the last casting of
their integuments, their development is completed.
In the higher hexapod insects, such reproduction has been seen in
only the larval state ; none of them, in its perfect state, can reproduce
an antenna, or any other member. The Myriapoda, then, are, in their
reparative power, equal to the larvae of the higher insects, and nearly
all th^power for formation which these manifest, appears to be exhausted
m the two later metamorphoses.
The case is the stronger, as illustrating the expenditure of power in
metamorphoses, when the higher insects are compared with the Arach-
nida; for in these, which attain their perfect state through more direct
development, the reparative power remains equal to the reproduction of
limbs and antennae. A yet stronger contrast is presented between the
higher insects and the' several species of salamander, in which so profuse
a reproduction of the limbs has been observed ; for though they be so
much higher in the scale of animal life, yet the amount of change in
external form and habits of life, through which they pass, in their deve-
l<qiment from the embryo to the perfect state, appears less than that
accomplished in the metamorphoses of insects.
Many instances, besides those which I have cited, appear to support
this rule, that the reparative power, in each perfect species, whether it
be higher or lower in the scale, is in an inverse proportion to the amount
of change through which it has passed in its development from the em-
biyonic to the perfect state. And the deduction we may make from
them is, that the powers for development from the embryo are identical
with those exercised for the restoration from injuries : in other words,
that the powers are the same by which perfection is first achieved, and
by which, when lost, it is recovered.
This is, again, generally confirmed in the instances of the Y ertebrata ;
but of the repair in these, or at least in the highest of them, I shall have
to speak so exclusively in the future lectures, that I will now only say
that, in man and other mammalia, a true reproduction after loss or injury
seems limited to three classes of parts : —
1. To those which are formed entirely by nutritive repetition ; such as
the blood and epithelia.
2. To those which are of lowest organization, and (which seems of
more importance) of lowest chemical character ; as the gelatinous tissues,
the cellidar and tendinous, and the bones.
8. To those which are inserted in other tissues, not as essential to
their structure, but as accessories, as connecting or incorporating them
with the other structures of vegetative or animal life ; such as nerve-
fibres and bloodvessels.
With these exceptions, injuries or losses in the human body are capable
of no more than repair, in its most limited sense ; t. e., in the place of
116 OBKBBAL OOKSIDBBATIONS ON THB BBPAIB AHD
what is lost, some lowly organized tissue is formed, which fills up the
breach, and suffices for the maintenance of a less perfect life.
I may seem in this, as in some earlier lectures, to hare been discussing
doctrines that can hardly be applicable to our daily practice, and with
illustrations drawn from objects in which surgeons may have but little
interest. Let me, then, if only in apology, refer to some of the conside-
rations which are suggested by studies such as these. Let mB^ first,
express my belief that, if we are ever to escape from the obscurities and
uncertainties of our art, it must be through the study of those highest
laws of our science, which arc expressed in the simplest terms in the
lives of the lowest orders of creation. It was in the search after the
mysteries — ^that is, after the unknown highest laws— of generation, that
the first glance was gained of the largest truth in physiology ; the truth
6f the development of ova through partition and multiplication of the
embryo-cells. So may the study of the repair of injuries sustained by
the lowest polypes lead us to the clearer knowledge of that law, in
reliance upon which alone we dare to practise our profesrion ; the law
that lost perfection may be recovered by the operation of the powers by
which it was once achieved. Already, in the facts that I have qnot^
from Sir Ghraham Dalyell, we seem to have the foreshadowing of those
through which the discovery may be made.
Then, let us not overlook those admirable provisions, which we may
find in the lives of all that breathe, against injuries that, but for these
provisions, would too often bring them to their end before their appointed
time, or leave them mutilated to finish a painful and imperfect life. We
are not likely to undervalue, or to lose sight of, the design of all such
provisions for our own welfare. But we may better appreciate these, if
we regard them as only of the same kind as those more abundantly sup-
plied to creatures whom we are apt to think insignificant ; indeed, so
abundantly, that, as if with a consciousness of the facility of repair, self-
mutilation is commonly resorted to for the preservation of life. When
the Ophiurse, or any of the brittle Star-fishes, break themselves t6 frag-
ments, and disappoint the grasp of the anxious naturalist, they probably
only repeat what they are instinctively taught to do, that they may elude
the jaws of their more ravenous enemies. But death would be much
better than such mutilation, if their rays could not be reproduced almost
as easily as they can be rejected. The experimentalist, too, who cuts off
one or the other end of any of the Anellata, perhaps only puts them to
a necessity to which they are liable from the attacks of their carnivorous
neighbors. Almost defenceless, and so easily mutilated, their condition,
were it not for their faculty of reproduction, might be more deplorable
than that of any other creature; and even their existence as species
might have been endangered long ago. It would almost seem as if the
species that have least means of escape or defence from mutilation were
those on which the most ample power of repair has been bestowed ; an
BEPBODUCTIOH OY INJURED AND L08T PABT8. 117
admirable instance, if it be only generally true, of the beneficence that
has provided for the welfare of even the least (as we call them) of the
fiying world, with as much care as if thej were the sole objects of the
Divine regard.
Lastly, if I may venture on so high a theme, let me suggest that the
instances of recovery from disease and injury seem to be only examples
of a law yet larger than that within the terms of which they may be
oomprised ; a law wider than the grasp of science ; the law that expresses
our Creator's will for the recovery of all lost perfection. To this train
of thought we are guided by the remembrance that the healing of the
body, was ever chosen as the fittest emblem of His work, whose true
mission was to raise man's fallen spirit and repair the injuries it had sus-
tuned ; and that once, the healing power was exerted in a manner pur-
posely so confined as to advance, like that which we can trace, by pro-
gressive stages to the complete cure. For there was one, upon whom,
when the light of Heaven first fell, so imperfect was his vision, that he
saw, confusedly, ^^ men, as trees walking ;" and then, by a second touch
of the Divine Hand, was ^^ restored, and saw every man clearly." Thus
guided by the brighter light of revelation, it may be our privilege, while
we study the science of our healing art, to gain, by the illustrations of
analogy, a clearer insight into the Oneness of the plan by which things
spiritual and corporeal are directed. Even now, we may trace some
analogy between the acts of the body and those of man's intellectual and
moral nature. As in the development of the germ, so' in the history of
the human spirit, we may discern a striving after perfection ; after a per-
fection, not viewed in any present model (for the human model was
marred almost as soon as it was formed), but manifested to the enlightened
Reason in the ^^ Express Image" of the "Father of Spirits." And so,
whenever, through human frailty, amid the violences of the world, and
the remaining " infection of our nature," the spirit loses aught of the
perfection to which it was once admitted, still its implanted Power is ever
urgent to repair the loss. The same power, derived and still renewed
from the same Parent, working by the same appointed means, and to the
same end, restores the fallen spirit to nearly the same perfection that it
had before. Then, not unscarred, yet living — "fractus sed invictus" —
the Spirit still feels its capacity for a higher life, and presses to its
immortal destiny. In that destiny the analogy ends. We may watch
the body developing into all its marvellous perfection and exact fitness
for the purpose of its existence in the world ; but, this purpose accom-
plished, it passes its meridian, and then we trace it through the gradual
decays of life and death. But, for the human Spirit, that has passed
the ordeal of this world, there is no such end. Emerging from its im-
prisonment in the body, it soars to the element of its higher life : there,
in perpetual youth, its powers expand, as the vision of the Infinite unfolds
before it ; there, in the very presence of its Model, its Parent, and the
Spring of all its Power, it is " like Him, for it sees Him as He is."
118 BEPABATIYE MATERIALS.
LECTURE VIII.
THE MATERIALS FOR THE REPAIR OF INJURIES.
Ik the present lecture I propose to give a general account of the
materials employed for the repair of some of the injuries inflicted
on the human body.
I hope I do not err in thinking that the most advantageous mode of
treating this subject will be to confine myself to that class of injuries
which may be called visible breaches of continuity ; such as wounds and
fractures. For, in regard to the recovery from diseases, our knowledge
of the effects of any disease seems, as yet, too imperfect for us to trace
the stages by which the morbid state reverts to that which is healthy.
We may be sure it is in conformity with the same general laws as those
of recovery from injury, and almost sure that it is by the gradual
improvement of the particles that in succession replace those altered by
disease. But the whole details of the process have yet to be discovered*
Even within the narrower field of the repair of breaches of continuity,
I must yet assign to myself a closer limit. A future lecture will be
devoted to the healing of fractures ; in this, therefore, I shall speak
almost exclusively of the healing of divided soft parts ; and I shall take,
as the chief and typical examples, the repairs of wounds made in opera-
tions. References to the healing of other injuries may, however, be
made by the way, and for collateral illustration.
Modem surgery has shown how right Mr. Hunter was, when, in the
very beginning of his discussion concerning the healing of injuries, he
points out, as a fundamental principle, the difference between those two
forms of injuries of which one is subcutaneous, the other open to the
air. He says : " The injuries done to sound parts I shall divide into
two sorts, according to the effects of the accident. The first kind con-
sists of those in which the injiu-ed parts do not communicate externally,
as concussions of the whole body, or of particular parts, strains, bruises,
and simple fractures, which form a large division. The second consists
of those which have an external communication, comprehending wounds
of all kinds and compound fractures.'** And then, he says, " The inju-
ries of the first division, in which the parts do not communicate exter-
nally, seldom inflame ; while those of the second commonly both inflame
and suppurate."
In these sentences Mr. Hunter has embodied the principle on which
is founded the whole practice of subcutaneous surgery ; a principle of
which, indeed, it seems hardly possible to exaggerate the importance.
• Works, vol iii. p. 240.
BBPAEATIVB MATERIALS. 119
For, of the two injuries inflicted in a wound, the mechanical disturbance
of the parts, and the exposure to the air of those that were covered, the
exposure, if continued, is the worse. Both are apt to excite inflamma^
tion ; but the exposure excites it most certainly, and in the worse form ;
i. €., in the form which most delays the process of repair, and which is
most apt to endanger life. Abundant instances of this are shown in the
difference between a simple and a compound fracture, though the former
may have been produced by the greater violence; or, between a simple
fracture, even with much violence, extending into a joint, and an open
wound, never so gently made into one. Or, for parallel instances, one
may cite the rarity of suppurations after even extensive ecchymoses, and
their general occurrence when wounds are left open.
I had frequent occasion to observe these differences, in a series of
experiments made for the illustration of the healing of divided muscles
tnd tendons. Some of these were divided through open wounds, and
some by subcutaneous section ; and the recital of a single experiment
may afford a fair example of the difference of results that often ensued.
Jr the same rabbit, the tibialis anticus and extensor longus digitorum
were divided on the right side with a section through the skin ; on the
left, with a subcutaneous section, through a small opening. Twelve
days afterwards the rabbit was killed. The wound on the left side
was well repaired, and with comparatively little trace of inflamma-
tion : the gap on the right was closed in with a scab, and an imperfect
scar, but under these was a large collection of pus, and no trace
of a reparative process. The contrast is the stronger, because in
all these cases there is, unavoidably, more mechanical violence inflicted
in the gradual subcutaneous division than in the simple open wound.
And, it must be added, that a speedy closure of the external wound made
in an open section may bring the case into more favorable conditions
than those of a subcutaneous wound made with more violence. This,
also, I saw in some of the experiments : a clumsy subcutaneous division
of one Achilles tendon excited great inflammation about it ; while the
open section of the other tendon in the same rabbit was quickly and well
repaired, if the external wound had been speedily united, and had suffi-
ciently soon converted the open into a subcutaneous injury.
Still, what Mr. Hunter said is true, especially in woimds in our own
bodies: subcutaneous wounds seldom inflame; open wounds generally
both inflame and suppurate. It will be a principal object of this lecture
to show something like an anatomical reason for this difference, in the
fact that the materials produced for the repair of open wounds are not
usually the same, or, at least, do not develope themselves in the same
manner, as those for the repair of closed or subcutaneous ones. The
physiological and nearer reason is probably to be discovered in the in-
fluence of oxygen abnormally admitted to the tissues, and producing in
them such effects as are more nearly traced in the phenomena of inflam-
mation, and will be described in future lectures.
120 BBPARATIYE MATERIALS.
Before spealdng of the materials for repair, I must briefly state tliat
the healing of open wounds may be accomplished by five different modes:
namely, 1. By immediate union ; 2. By primary adhesion ; 3. By
granulation ; 4. By secondary adhesion, or the union of granulations ;
5. By healing under a scab. The repair of subcutaneous wounds may
be effected by immediate union, but is generally accomplished by connex-
ion, or the formation of bonds of union between the divided and re-
tracted parts. Very rarely it is effected by means of granulations
without suppuration.
Of these modes, which I hope to describe hereafter in detail, it is the
peculiarity of the first, or process of immediate union, that it is accom-
plished by the mere reunion or re-joining of the divided parts, without
the production or interposition of any new material. In all the others,
new material is produced and organized. This process of immediate
union corresponds with what Mr. Hunter called "union by the first
intention." It is not the same as that which, in modem surgery^ is
called union by the first intention ; for that is the same as Mr. Hunter
named " union by adhesion/' or " by the adhesive inflammation," aiid is
effected, as he described it, by the organization of lymph interposed
between two closely approximated wounded surfaces. Mr. Hunter main-
tained that union by the first intention is effected by means of the fibrine
of the blood extravasated between the surfaces of the injured part, which
fibrine, there coagulating, adheres to both the surfaces, becomes orga-
nized, and forms a vascular bond of union between them.* DoubtlesSi
Mr. Hunter was, in this, in error ; but, as the blood extravasated in
wounds is not without influence on their repair, I will endeavor to state
the several modes in which it may, when thus extravasated, be finally
disposed of.
There are ample evidences for believing that masses of effused, or
stagnant and coagulated, blood may be organized ; i. e. may assume the
characters of a tissue, and may coalesce with the adjacent parts and
become vascular. These evidences include cases of blood effused in
serous sacs, especially in the arachnoid ; of clots in veins organizing into
fibrous cords, or, after less organization, degenerating into phlebolithes ;
clots organizing into tumors in the heart and arteries ; and the clots so
organized above ligatures on arteries as to form part of the fibrous cord
by which the obliterated artery is replaced. These last cases afford most
conclusive evidence, because they have been very carefully investigated
in a series of experiments and microscopic observations, by Dr. Zwicky.f
In 1848, I had the opportunity of examining a specimen which, more
fully than any other I had seen, confirmed Zwicky's account of the mode
in which blood-clots become organized. It supplied, too, some facts
which appear important to the present subject. It was obtained from an
• Works, vol. iii. 253.
t Die Metamorphose des Thrombus. Zurich, 1845.
BLOOD. 121
■nne penon, bj mj fnend, Mr. Holmefl Coote. A thra layer of pale
Uood-eolored and raddjr membrane lined the whole intomal surface of
Ae cerebral dura mater, and adhered closelj to it. Its color, the ezis-
teaee of patches of blood-clot imbedded in it, and all ita other characters,
ntii&ctorily proved that it had been a thin clot of blood, — an example
of Mieh as are effnaed in apoplei^ of the cerebral membranes, and are
fiDj described by Mr. Preacott Hevett.* Komerous small vessels could
be Ken passing from the dura mater into this clot-membrane ; and with
tlie microscope, while they were still full of blood, I made the sketch
vhich is here engraved (Fig. 13, A). The arrangement of the blood-
Fosels bean a close resemblance, but, perhaps, more in its irregularity
(ban in any poutive characters or plan, to that which exbts in fake
membrane formed of organized lymph : but the veseek were, I think,
generally larger.
Such were the bloodvessels of this organized clot. Its minute struc-
ture, as represented above (B.), showed characters which are of peculiar
interest, because of their resemblance to those observed in the material
that is commonly formed in the repair of subcutaneous injuries. In the sab-
stance of what else appeared like a filamentous clot of fibrine, sprinkled
over with minute molecules, the adtUtion of acetic acid brought into view
corpuscles like nuclei, or cytoblasts, very elongated, attenuated, and, in
some instances, like short strips of flat fibre. Of course, such corpus-
des are not to be found in any ordinary clot of fibrine ; they exactly
resemble such as may be found in certain examples of rudimental cellu-
lar tissue, and^ among these, in the material for the repair of subcuta-
• UML-Cbit. TniM. toL xxvUi.
122 . BLOOD.
neons injnries. In short, the minnte structure of this clot now organised
was an example of what I shall have often to refer to nnder the name of
" nucleated blastema.***
With such evidence as this of the organization of a thin layer of
blood-clot, and of the development of its fibrine being apparently iden-
tical with that of the material commonly formed for the repair of subcu-
taneous injuries, I was surprised to find that extravasated blood can,
commonly, have no share at all in the reparative process.
One of the best proofs of this is, that scarcely the smallest portion of
blood is effused in the cases in which the largest quantity of reparative
material is produced in the shortest time, and in which the healing pro-
cess is most perfectly accomplished. In twenty cases in which I divided
the Achilles tendon in rabbits, I only once found, in the subsequent
examinations, a clot of extravasated blood in the track of the wound.
In this case, I believe, the posterior tibial artery was wounded : for in
all others, and in similar divisions of muscles, unless a large arterial
tnmk were cut, the only effusion of blood was in little blotches, not in
separate clots, but effused or infiltrated in the cellular tissue near the
wound. In some cases there was blood-stained infiltration of the inflam-
matory products, but in none were there such clots as could be organised
into bonds of union. In short, parts thus divided scarcely bleed : what
blood does flow escapes easily through the outer wound, as the surround-
ing tissues collapse into the space left by the contracting parts ; or, what
remains is infiltrated into the tissues, and forms no separate clot.
It is the same with fractures. In a large proportion of these, one
finds no clots lying between the fragments where they are united, and
only very small spottings of blood, like ecchymoses, in or beneath the
periosteum. The abundant extravasations that commonly exist in the
subcutaneous tissue are generally confined to it: they are not continued
down to the periosteum or bone.
In all these cases, then, we have sufficient proof that extravasated
blood is not necessary for union by the first intention, or for any other
mode of repair, in the simple fact that where the repair is best, and the
material for it most ample, no blood is so extravasated as to form a clot
that could be organized.
But, though this may be the usual case, the question still remains —
When blood is effused and coagulated between wounded surfaces, how
are the clots disposed of? For, often, though not generally, such clots
are found in wounds, or between the ends of a broken bone, or a divided
tendon when an artery by its side is cut ; and in most operation-wounds,
one sees blood left on them, or fiowing on their surfaces, after they are
done up. How, then, is this blood disposed of?
* The de9cription here given has been fully confirmed by the examination of a similar
membranous clot, the vessels of which were beautifully ii^ected by Mr. Gray (Pathol.
Trans.) ; and more recently by that of one injected by Mr. Coote.
BLOOD. 128
If efiiiBed in large quantify, so as to fonn a volaminons clot, and
especiallj if so effused in a wonnd which is not perfectly excluded from
the air, or if effused in even a subcutaneous injury in a person whose health
is not good, it is most likely to excite inflammation ; and the swelling of
the wounded parts, or their commencing suppuration, will push it out
of the wound. Thus we often see blood ejected.
Bat, in more favorable circumstances, the blood may be absorbed ;
tnd this may happen whether it have formed separate clots, or, more
readily, when it is infiltrated in the tissues. What I have seen, how-
erer, in the experiments to which I have already referred, leads me to
dissent from the account commonly given of the absorption of blood
thus effxised. The expressions generally used imply that the first thing
towards the repair of such a wound is the absorption of the extravasated
blood ; and that then, in its place, the lymph or reparative material is
produced. But this can hardly be the case ; for the absorption of blood
is a very slow process, and commonly requires as much time as would
suffice for the complete healing of a wound, or even of a fracture. Not
to mention the very slow absorption of the extravasations of blood in
ijM^Iexy, or in serous sacs, I have found the blood effused in the subcu-
taneous tissue and the muscles, after a simple fracture, scarcely changed
It the end of five weeks ; that in a tied artery was as little changed after
seven weeks : and even in common leech-bites we may sometimes find
the blood-corpuscles, in little ecchymoses, imchanged a month after their
extravasation ; yet in much less time than this it is commonly implied
that all the blood extravasated in an injury is cleared quite away, that
lymph may occupy its place. My impression is, that this opinion is
founded on imperfect observations. Blood is supposed to be effused in
all subcutaneous injuries ; and where it is not found, it is supposed to
have been absorbed ; the truth rather being, that, where no blood ap-
pears, none ever was.
The true method of the absorption of blood left in a wound seems to
be, that it is enclosed within the reparative material, and absorbed by
the vessels of that material as its organization proceeds. The best in-
stance in support of this that I have seen was in the case of a rabbit's
Achilles tendon, divided subeutaneously six days before death. The
reparative process had proceeded favorably, and as strong a band of
union as is usual at that period was formed of the new reparative mate-
rial deposited between the retracted ends. On slitting open this band, I
found within it a clot of blood, such as must have come from a large
vessel ; and this clot was completely enclosed within the new material ;
not closely adherent to it, nor changed as if towards organization ; but
rather, decolorized, mottled, and so altered as clots are in apoplexy
before absorption.
I believe that this case only showed in a very marked manner what
usually happens with blood thus effused and not ejected : for it is quite
124 BLOOD.
common, after the division of tendons, to find new reparative material, if
not containing distinct clots, yet blotched with the blood that was infil-
trated in the tissue in which the reparative material is deposited : and
even when the repair of a fracture was nearly perfect, I have still found
traces of blood-corpuscles enclosed in the reparative material, and dege-
nerating, as if in preparation for absorption.
Ejection and absorption are, doubtless, the usual means by which blood
effused in injuries is disposed of; yet I feel nearly sure it may in some
instances become organized, and form part of the reparative material
The cases of manifest organization of blood already referred to leave no
doubt of the possibility of this happening : its occurrences can no longer
be set aside as a thing quite improbable. The only question is, whether
blood effused in injuries has been seen organized. Now I think no one
familiar with Hunter's works will lightly esteem any statement of his as
to a matter of observation. He may have been sometimes deceived in
thinking that he saw blood becoming organized in subcutaneous injuries
(for subcutaneous granulations are sometimes very like partiaUy decolo-
rized clots) ; yet I believe he was often right : for sometimes one finds
clots of blood about the fractured ends of bones which have every ap-
pearance of being in process of organization. They do not look mottled,
or rusty, or brownish, as extravasated blood does when it is degenerating,
preparatory to its absorption ; but they are uniformly decolorized to a
pinkish-yellow hue. They have more appearance of filamentous stmo-
ture than recent clots have ; and they are not grumous or friable, like
old and degenerating ones, but have a peculiar toughness, compactness,
and elasticity, like firm gelatine. When clots are found in this condition,
I believe it is a sign that they were organizing : for this is the condition
into which, commonly, the clot in a tied artery passes in its way to be
fully organized ; and (which is very characteristic) you may find clots kk
the track of wounded parts thus changing, as if towards organization,
while those about them, and out of the way of the reparative process,
' are degenerating.
On the whole, then, I believe we may thus generally conclude con-
cerning the part that blood, when it is extravasated, takes in the repair
of injuries: —
1. It is neither necessary nor advantageous to any mode of healing.
2. A large clot, at all exposed to the air, irritates and is ejected.
8. In more favorable conditions the effused blood becomes enclosed in
the accumulating reparative material ; and while this is organizing, the
blood is absorbed ; and.
Lastly, it is probable that the blood may be organized and form part
of the reparative material ; but even in this case it probably retards the
healing of the injury.
I proceed now to the consideration of the new material which is pro-
LTMPH. 125
dnced for the repair <^ injuries that are not healed bj the immediate
onion. It is that to which the general name of lymph, or coagulable
lymph, is given.
Our notions concerning the properties of this substance, when once
formed for the repair of injuries, are derived almost entirely from exami-
nations of the lymph formed in acute inflammations, with which it is sup-
posed to be identical. The identity is far from being proved, but their
tfanilarity is in many particulars evident, and especially in that both
manifest, by their spontaneous coagulation, that they contain fibrine.
The ooagulum which is spontaneously formed in reparative material is,
in microscopic characters, like that of fibrine: chemically, too, they
appear alike : and the organisation of the fibrine of the blood in the com-
plete clot, as well as all the other circumstances which lead to the opinion
that fibrine is the principal material for organization into tissues, justifies
the belief that the lymph exuded for the purposes of repair has fibrine
for its principal constituent. However, when we speak of fibrine as the
chief reparative material, we must not have in mind the pure organic
eompoimd that minute chemistry might obtain, but rather that which
adats in the natural, and seemingly rough, state, — as fibrine, with some
fiktty matter, and some incidental saline constituents ; for all these are
found in all the specimens of coagulable lymph that have been examined ;
and doubtless they are essential, as the so-called ^^ incidental" principles
always are, to the due construction of the substance to be organized.
Regarding its vital properties, the essential character of the coagu-
lable lymph is its tendency to develope itself; a tendency which it has of
its own properties. It thus displays itself as a plasma or blastema ; a
fluid to be classed with those others that manifest the capacity to assume
organic structure; such as the lymph and chyle that develope them-
selves to blood, and the semen, which, at first fluid, gradually developes
itself into more and more complex structures.
The natural tendency of coagulable lymph is to develope itself into
the fibrous, or the common fibro-cellular or connective, tissue — the lowest
form of vascular tissue, and the structure which, in nearly all cases in
man, constitutes the bond by which disunited parts are again joined.
This is commonly formed, whatever be the tissue upon which the lymph
is placed, whether containing cellular tissue in its natural structure or
not. This, therefore, we may regard as the common or general tendency
of lymph ; but in certain cases the development of lymph passes beyond
this form, or deviates from it into another direction, in adaptation to the
special necessity of the part to be repaired. Thus, for the repair of bone,
the lymph may proceed a certain distance towards the development of
fibrous tissue, as if for a common healing ; but this fibrous tissue may
next ossify ; or, not forming fibrous tissue at all, the lymph may proceed
at once to the formation of a nearly perfect cartilage, and this may
ossify. In general, moreover, the character of the connective tissue that
126 LTMPH.
is formed in repair is adapted to that of the parts that it nnites. The
bond for the union of a tendon is much tougher than a common scar in
the skin ; the scar in skin is tougher and less pliant than that in mucous
membrane, and so on.
But, passing by, for the present, the instances of special development
of the reparative material, in adaptation to special purposes or injuries,
let me speak of its developement into fibrous, fibro-cellular, or connective
tbsue. I have said that, in its first production, the reparative material
is like the lymph of inflamed serous membranes ; at least, no charac-
teristic difference is yet known between these, which we might call re-
spectively, inflammatory and reparative lymph. Neither are there yet
any observations to show a difference in the primary characters of the
materials effused for the repair of injuries of different parts, or in diffe-
rent circumstances ; and yet such a difference, in even the original pro-
perties of the reparative lymph, is indicated by the fact, that, in different
circumstances, it may proceed to the same end — ^the formation of fibrous
tissue — ^by two different ways of development. The lymph or new
material, which is produced for the repair of open wounds, generally
developes itself into fibro-cellular tissue through nucleated cells ; that
formed for the healing of subcutuieous wounds as generally developes
itself into the same tissue through the medium of nucleated blastema.
Now, both these are repetitions of natural modes of development of
the same forms of tissue. And it must not appear an objection that
there should be two modes of development to the same perfect structure;
for this is usual, and has been observed in nearly all the tissues. In the
development of the bloodncorpuscles, a first set are formed from part of
the embryo-cells that form the germinal area, of the whole body of the
embryo ; and a second set are formed, I believe, exclusively from the
corpuscles of lymph and chyle. So it is with the cartilage, the musoolar,
and other tissues that are formed in the earliest periods of embryo-life.
At first they are developed from some of the embryo-cells ; yet in later
life no such cells are seen among them, but others appropriate to them,
and of different form. So also in the bones, which at first are developed
through cartilage, but in their subsequent growth are increased by ossifi*
cation of fibrous tissue ; and in the repair of which we shall find even
more numerous modifications of these different developments.
The development of the fibro-cellular or connective substance through
nucleated cells may be observed in the material of granulations, or in
that of inflammatory adhesions (whether in a serous sac or in a wound
healing by primary adhesion), in inflammatory indurations, and in the
naturally developed fibro-cellular tissue of many parts. The process is,
with slight and apparently not essential modifications, the same in aU ;
and is, I believe, almost exactly described by Schwann.
The cells first formed in granulations are spherical, palely or darkly
LTMPH. 127
nebnlons, from about l-lSOOth to l-2500tb of an ioch in diameter. Tbey
eontain a few shining, dsrk-bordered granules, and lie imbedded in a
' rariable qoantitj of clear pellucid gnbstance, b; whicb tbey are held
together, and irhich it ia hard to see, unless acetic add be added. When
water ia added, it penetrates the cells, and as they swell up their walls
ippear more distinct, and their contents are diffused. Some cells thus
liecome mncb larger and clearer, and show in their interior namerous
Tibrating molecnles : others display fewer molecules, but a disdnct, round,
dark-bordered nucleus, which appears attached to the inside of the cell-
rail. Such a nacleuB is rarely seen in granulation-cells, unless they are
distended with water : acetic acid, acting more quickly than water, brings
the nucleus more evidently and constantly into view, and often makes it
appear divided into two or three porUons-f
In the development of cellular or connective tissue from these cells,
whether in the natural structures or in those that are formed in disease or
after injury, the first apparent change is in the nucleus. It becomes more
distinct ; then oval (even before the cell does), and at the same time
clearer, brighter, like a vesicle tensely filled with pellucid substance.
One or two nncleoU now appear distinctly in it, and soon it attenuates
itself; but this it does later, or in a less degree, than the cell : for a com-
mon appearance is that of elongated cells bellied out at tbo middle by
the nucleus.
While these changes are ensuing in the nucleus, each cell also is
developing ita structure ; first becoming minutely, yet more distinctly,
granular and dotted ; then having its cell-wall thinned, or even losing it.
* DeTelopmsnt of gnnulalkm celli ; iha elongaled eelU in Ihe group below are iketched
■■ leu luagoiAed than Iboie abova.
t The gnnnlatiof^cfllli are very like the white or If mph-corpuaclei oT the blood : but Ihe
likeneM impliei nothing mors than the general fact ihat many nnictuiea which, in their per-
fect state, are wiilely diSerent in form u well na in of&ce, have, as to form, the aame luili-
mental elemsnu. The fact, oT which there are man/ other initances, seenii the more re-
markable, if we oontraM it with that alretulf mentioned, — that the aame perfect itriicture
maf bave more than one original or radimeDla] fbroi, and more ihsn one method of deve-
fctpment.
128 LYMPH.
It elongates at one or both ends, a^d thus are produced a variety of
lanceolate, caudate, or spindle-shaped cells, which gradually elongate
and attenuate themselves towards the filamentous form. As they thtn
change, they also group themseWes ; so that, commonly, one may find
the swollen part of each, at which the nucleus lies, engaged between the
thinner parts of the two or more adjacent to it. Thus, the filaments
into which the cells are developed are clustered or fasciculated : each
cell forming, I think, usually, only one filament, and long filaments
being sometimes formed by the attachment of the ends of two or more,,
each developed from a single cell.
The final disposal of the nuclei of these cells is not clear. In the
development of the cellular tissue formed in inflammation or granulating
wounds, they seem to waste and be absorbed. Certainly such nucleus-
fibres as Henle supposed to be formed from them are not found in recent
scars, though common in those of old standing.
In some granulations, but, I think, only in such as are formed on
bones, one may often find large compound cells, or masses or laminse of
blastema, of oval form, and as much as l-250th of an inch in diameter,
containing eight, ten, or more nuclei. They are like certain natural
constituents of the medulla of bone (as described by Kblliker* and
Bobinf) ; and like the bodies which are found constituting the chief part
of fibro-plastic tumors. Sometimes, also, even in the deeper parts of
granulations, cells are found expanded, flattened, scale-like, and nucleated,
as if approximating to the formation of epidermal cells.
Such, briefly, is the process for the development of fibro-cellular tissue
through nucleated cells as observed in granulations. Some modifications
of it may be noticed in certain cases, especially in regard to the propor-
tion that the cells bear to the substance in which they lie. In some
forms of granulations, as in some natural parts of the embryo, this sub-
stance is abundant ; and I presume that by its development or fibrilla-
tion it takes part in the formation of filaments. But none of the modi-
fications afiect the essential characters of the process.
The development of fibro-cellular or fibrous tissue through nucleated
blastema is, as I have already said, best observed, among the processes
of repair, in the organization of the material by which, in most cases,
the bonds of connexion after subcutaneous wounds are formed. It is
the same process which Henlc J regards as the only mode of development
of the fibro-cellular and fibrous tissues.
Of the union of divided tendons I hope to speak more fully in a future
lecture. For the present purpose, and in illustration of the development
• Mikrosk. Anntomie, Fig. 113, 121.
t Bull, de la Soci6t6 de Biologie, 1849, p. 150.
% Allgemeine Anatomic. A similar process is described by Reichert, Zwicky, and Ger-
lach.
of fibro-cellular or fibrooa tissue from nucleated blastema, it may be
niongli to state tKat, when the first exudation of the products of the
inflammation, excited b; the Tiolence of the iround, ie completed, a
qautit/ of finely molecular or dimly-shaded substance, like homogeneous
or dotted fibrine, begins to appear in the space in which the bond of
inion is to be formed. This substance is mfiltrated in the tissue that
eollapBes into the space between the retracted ends of
the tendon. At first there is no appearance of nuclei ~~ "
or oytoblasts in it : it 8eem« to be merely a blastema
of fibrine ; bat, as it acquires firmness and distinctness,
the nuclei appear in it. These seem to form out of .
collecting clusters of granules ; they presently appear '
is oral bodies, with dark hard outlines, soon becoming
elongated ; they have clear contents, without nuclei :
tbey are irregularly scattered, but so firmly imbedded l
in the blastema that, in general, they cannot bo dis-
lodged. They may be seen in rery fine fragments
without reagents ; but, commonly, the application of
acetic acid is necessary to make them distinct, by making the inter*
mediate substance transparent, while the nuclei themselves appear to
acquire darker edges and shrivel a little. The nuclei undergo compara-
tively little change, while the blastema in which they are imbedded is
Boqniring, more and more distinctly, the filamentooa appearance, and
then the filamentous structure. Only, they appear to elongate, and to
attenuate themselves, and to grow more irregular in their outlines, as if
by shrivelling, or by slight branchbg.
The blastema may become at length perfect fibrOHiellular or fibrous
tisflue ; a tissue not to be distinguished from that found in normal condi-
tions. I have not been able to find, as Henle describes, that the nuclei
are developed into fibres. In the process of repair by tissue thus
developed, as well as by that which is formed through cells, my impres-
sitHi is that the nuclei finally shrivel ; gradually contracting into little
crooked or branched lines, and at length disappearing : for, as I have
already said, well-formed nucleus-fibres, or such elastic yellow fibres as
might be developed from them, do not generally occur in cicatrices of
recent formation, or in the large bonds of union by which divided tendons
are healed.
I have been thus minute in the account of these two modes of develop-
ment of fibro-cellular tissue, prevailing alike in the natural structures
and in the materials of repair, because the knowledge of them may enable
ns to settle some questions respecting all the modes of healing, and
because it seems to point out the essential anatomical difierence in the
healing of open and of subcutaneoua wounds, with disconnexion of
divided paxts.
180 BEPARATIVE MATBBIAL8.
The general truth appears to be (as aLreadj stated), that the materitl
of repair for subcutaneous wounds of soft parts is developed through the
formation of nucleated blastema ; while that for repair by primary adhe*
sion, and by granulation, is developed through nucleated cells. Now,
since both these methods of development are, as I have already sud,
imitations of natural methods, we might suppose that they are, there-
fore, both alike natural or healthy processes ; alike sure to pass to their
purposed end, safe from disease or degeneration. But, if we consider
also the morbid conditions in which these two methods of development
occur, we may find that the development through cells is characteristic
of a less perfect process of healing than that accomplished with the
nucleated blastema that appears to originate in a fibrinous exudation.
For, in describing the products of inflammation, I shall have to show,
that in general, the inflammatory exudations which occur in plethoric
sthenic conditions of the system, or in local disease in persons otherwise
soimd, have the aspect of fibrinous substance, like the materials whioh
are produced in subcutaneous injuries, and arc developed through
nucleated blastema ; while, on the other hand, the inflammatory exuda*
tions in debilitated persons, and in asthenic blood-diseases, assume a cor-
puscular structure, like that of granulations upon open wounds.
Let me, however, in conclusion, state that, although I have described
the two modes of development of fibro-cellular or fibrous tissue for the
healing of wounds as if they were always as separate as they are distinct,
yet they may co-exist, and probably often do so. In the repair of many
wounds, the two materials, namely, that which is to be developed through
nucleated cells, and that whose progress is to be through nucleated
blastema, may be mixed. Thus, in subcutaneous wounds and injuries,
the first consequence of the mechanical violence is the exudation of a
common inflammatory product, which makes the cellular tissue oedema-
tons, and usually organizes itself into nucleated cells. Thus you find
the space between the retracted parts of divided tendons for about two
days. But, then, the more proper and purer material of repair is pro-
duced ; and this, increasing in an inverse proportion to the degree of
inflammation, soon overwhelms the former product of inflammation, and
is developed into the nucleated blastema. Still, for many days, traces
of the inflammatory product may be discerned mingled with the blastema,
confusing its appearance, but, I believe, finally organizing with it into
the bond of union. So, in divided muscles, and in simple fractures, the
inflammatory exudation, produced in consequence of the first violence,
appears to mingle and develope itself with the more proper material of
repair ; but they bear an inverse proportion to one another, and the more
manifest the signs of the inflammation, the less is the quantity of the
proper reparative material, and the slower, in the end, the process of
repair.
On the other hand, I think that in the ordinary healing of open
HSALIKG BT IMMEDIATE UNIOE. 181
wounds, which are soon brought together by sutures, or other appropriate
means, there may be less than the commonlj observed formation of
nucleated cells, and some of the reparative material may be developed
throngh the nucleated blastema. Or, when the different materials are
not mingled at the same spot, yet, in a single wound, different parts may
be healed by the organisation of one or other material, according to the
diBgtee of inflammation that is in each part present.
LECTURE IX.
THE PROCESSES OP REPAIR OF WOUNDS.
I PROCEED now to the description of the several modes of healing of
wounds, and shall at present speak of only such wounds as are externally
open. Among the modes which I enumerated, the first was that which,
as I stated in the preceding lecture, is effected by immediate union. It
corresponds with what Mr. Hunter called union by the first intention ;
but, since that term has been applied more recently to another mode of
healing, I have adopted the term " immediate union" from Dr. Macartney,
who, so far as I know, was the first to observe clearly that the healing of
wounds may be effected ^^ without any intervening substance, such as
blood or lymph."* He says — "The circumstances under which immo-
late union is effected, are the cases of incised wounds that admit of
being with safety and propriety, closely and immediately bound up.
The blood, if any be shed on the surfaces of the wound, is thus pressed
out, and the divided bloodvessels and nerves are brought into perfect
contact, and union may take place in a few hours ; and as no inter-
mediate substance exists in a wound so healed, no mark or cicatrix is
left behind.
" We liave familiar examples of this mode of healing in slight cuts re-
ceived on the fingers, which, after being bound up, if no inflammation be
induced, perfectly heal without the individual having any unpleasant
sensation in the part after the moment of the infliction of the wound.
A case has been lately communicated to me, of a considerable cut of the
hand having been cured by this mode of direct union, without any sen-
sation of pain, in the short space of four or five hours."
It is singular that Dr. Macartney should speak of the process of imme-
diate union occurring in so few and very trivial instances as these ; for
it seems certain that many even very large wounds are usually, in favor-
able circumstances, thus healed. The characteristics of this mode are,
* Treatise on Inflammation, p. 49.
182 HEALING BY IMMEDIATE UNION.
that the divided parts, being placed in exact contact, simply conjoin or
reunite : no blood or new material is placed between them for a connect-
ing bond, and no sign or product of inflammation is present. All theee
characters meet in such cases as the favorable union of flaps of skin,
which have been reflected from the subjacent parts, and are then replaced
or transferred to some other adjacent wounded surface.
The instances in which I have best observed it have been after wounds
reflecting portions of the scalp, and after operations for the removal of
the mammary gland. In these operations, as you know, the usual pro-
ceeding is to remove some of the skin, including the nipple, and to
uncover the rest of the surface of the gland by reflecting from it an upper
and lower flap of skin. Then, the gland being removed, these flaps,
which are often of considerable extent, are laid down upon the parts on
which the base of the gland rested, chiefly upon the fascia over the great
pectoral muscle.
One of the first specimens I examined well illustrated the healing that
may now ensue. It was taken from a woman thirty-three years old,
whose breast and several axillary glands were removed for cancer. Her
general health seemed good, and all went on well after the operation.
The flaps, which were of course very large, had been carefully laid down,
strapped with isinglass plaster, and well tended. They appeared to unite
in the ordinary way, and there remained only a narrow space between
their retracted edges, in which space granulations arose from the pectoral
muscle. Three weeks after the operation these were making good pro-
gress towards cicatrization ; but erysipelas and phlebitis ensued, and the
patient died in four or five days. •
I cut ofi" the edges of the wound with the subjacent parts, expecting to
find the evidences of union by organized lymph, or, possibly, blood.
But neither existed ; and the state of parts cannot be better described
than by saying that scarcely the least indication remained of either the
place where the flap of skin w^as laid on the fascia, or the means by which
they were united. It was not possible to distinguish the relation which
these parts held to each other from that which naturally exists between
subcutaneous fat and the fascia beneath it. There was no unnatural
adhesion ; but, as the specimen^ which is in the Museum of St. Bartholo-
mew's, will still show, the subcutaneous fat which did lie over the mam-
mary gland was now connected with the fascia over the pectoral muscle,
just as (for example) the corresponding fat below the clavicle is naturally
connected to the portion of the same fascia that lies there. The parts
were altered in their relations, but not in their structure. I could find
small points of induration where, I suspect, ligatures had been tied, or
where, possibly, some slight inflammation had been otherwise excited;
and one small abscess existed under the lower flap. But with most care-
ful microscopic examination, I could discover no lymph or exudation-cor-
puscles, and only small quantities of what looked like the debris of such
HBALIHG BT IMMEDIATE UNION. 188
oil-particIes or corpuscles of blood as might have been between the cut
surfaces when the flaps were laid down. In short, we cannot otherwise
or more minutely describe this healing than by the term ^^ immediate
union :" it is immediate, at once in respect of the absence of any inter-
mediate substance placed between the wounded surfaces, and in respect
of the speed with which it is accomplished.
Opportunities of examining wounds thus healed being rare, I made
three experiments on rabbits (with my friend Mr. Savory), and found
the description I have just given quite confirmed. A portion of skin,
which my extended fingers would just cover, was raised from the back of
a rabbit, replaced, and fastened down with a few sutures. Three days
afterwards the rabbit was killed. The edges of the wound were slightly
retracted, and the space between them was covered with scab : for about
half an inch under the edge of the replaced flap of skin, the tissue was
inflamed and infiltrated with exudation-matter ; but beyond this no trace
of the injury or of its healing could be seen. The parts appeared as
they had appeared before the operation. Even the microscope could
detect only a slight infiltration of inflammatory matter, which one might
certainly ascribe to the wound being open at its edges, and to some hairs
having by accident been enclosed under the flap when it was replaced.
Of course, it is only from such examinations as these after death, that
we can speak certainly of the absence of inflammation and of all interme-
diate uniting substances ; yet confirmatory evidence may be obtained
from the examination of any such wound during life, — I mean in any
such case as that of a flap of skin raised up, then laid down on the sub-
jacent wounded surface, and there uniting favorably ; or in any case of
that kind of plastic operation in which a flap is raised, and then made to
slide to some further position. In such cases, with favorable progress,
no sign of inflammation is observed ; though, if the skin were in even a
small degree inflamed, it could scarcely fail to be manifested by the
ordinary appearances of redness and heat. If the flap be pressed, no
fluid oozes beneath its edges (I speak, of course, of only such cases as
are making favorable progress) ; and after one or two days, according to
the extent of the wound, the flap will move on the subjacent parts, not
with the looseness of a part separate from them, nor with the stifiness of
one adherent through inflammation, but with the easy and pliant sliding
which is peculiar to the natural connexion of the skin with the subjacent
fascia.
Such is the nature of "immediate union ;*' the best imaginable process
of healing. Two conditions appear essential to it: first, exactness of
the coaptation of the wounded surfaces ; and secondly, the absence of all
inflammatory process.
To obtain the former, the simple replacement of the raised pieces of
skin may sometimes be sufficient. But there is a class of cases to which
this mode of healing is peculiarly applicable, and in which more than this
184 HSALiira bt primary adhesion.
may be required : I refer to the removal of large subcutaneous tumors, —
fatty tumors and the like, — ^where, after the operation, large cayities are
left, and commonly left to granulate. In these cases I beliere that
modem surgery does not often enough employ the older method of care-
fully and softly padding the parts, and of so bandaging them that the
exposed surfaces may be held in contact for the one, two, or three days
necessary for immediate union. Many surgeons, I know, commonly
employ these means, but by many they are avoided, through fear of
exciting inflammation by over-heating the parts, or hindering the dis-
charge of secreted fluids. Doubtless, no single rule of management
would be safe ; but I think, with regard to this fear of exciting inflamma-
tion, it need not be entertained, if the means I have alluded to be em-
ployed only during the first two or three days after the infliction of the
wound. For one may generally observe that, for at least two or three
days after such an injury as an amputation, the raising of a flap of skin
in a removal of the breast, or the like, scarcely any reparative process
appears in the parts that are kept from contact ; no granulations are
formed, no pus secreted, only a little serous-looking fluid oozes from
them. Now, during this calm, which would certainly not be disturbed
by the parts being softly padded and kept in perfect rest, the immediate
UBion may be accomplished. K, through any untoward circumstance, it
be not in this period completed, its occurrence is, I believe, impossible,
and then the means more appropriate for other methods of healing may
be employed.
The attainment of the other necessary condition, the absence of inflam-
mation, is quite consistent with these means for insuring perfect and con-
tinued contact of the wounded surfaces. How the condition is to be ful-
filled I need not say : the means are some of those that are commonly
laid down for preventing inflammation from being, as it is said, more
.than is necessary for the union by the first intention ; and the best of
them are temperance, rest, and imiform temperature. The necessity of
observing them will appear the greater, if it is remembered that what is
wanted for immediate union is, not a certain undefined slight degree of
inflammation, but the complete absence of inflammation ; for the proba-
bility of the occurrence of immediate union may be reckoned as being in
an inverse ratio to the probability of inflammation occurring in the time
necessary for its accomplishment.
The second mode of repair that I enumerated, is that hj primary
adhesion.
This is the process which Mr. Hunter named union by adhesion, or
union by the adhesive inflammation. My reasons for preferring the
term " primary adhesion'* will presently appear. He says : " Where the
former bond of union'* [i. e., the union by blood or by the first intention]),
^^ is lost in a part, to produce a new one a second operation takes place,
HBALIKe BY PBIMABT ADHESION. 185
namely, inflammation/'* Obseire how carefnllj Mr. Hunter distinguishea
the case in which inflammation ensues, from that in which none is neces-
sary : and presently after — ^^ If the divided parts are allowed to remain
till the mouths of the divided vessels are entirely shut, inflammation will
inevitably follow, and will furnish the same materials for union which are
contained in extravasated blood, by throwing out the coagulated lymph ;
10 that union may still take place, though some time later after the ^vi-
sion of the parts. This inflammation I have called the adhesive." On
this sentence, Mr. Palmer, expressing the opinion entertained by all the
pathologists of ten or twelve years ago, says — ^^ It is now generally con*
siderid that union by the first intention and adhesive inflammation are
essentially the same processes, modified by the degree of inflammation.
Union by the first intention is uniformly attended with some degree of
pain and swelling, together with increased heat and vascularity, which,
taken conjointly, constitute the definition of inflammation." And again:
'^ According to the modem views, the modes of union above detailed"
[t.^, the modes of union included by Mr. Hunter under the union by
the first intention], ^^ are always accompanied by adhesive inflammation.
The parts are united, not by the extravasated blood becoming
vascnkur, but by the efiusion and organization of coagulable lymph."
After what I have said respecting the process of inmiediate union, it
may appear that Mr. Hunter was more nearly right than his successors.
It would be an instructive piece of the history of surgery, to show,
exactly, how his truth, being mixed with error, came therefore, to be
thrown away, and to make room for an error which had less truth mixed
with it. The stages of transition in opinions seem to have been, that,
first, sufficient reason was found for disbelieving Hunter's statement, that
blood forms the bond of union by the first intention ; then, as it was
aJBSumed that there must always be some intermediate bond, this, it
seemed, could be none but coagulable lymph. Now, coagulable lymph
being known only as the product of inflammation, it followed that inflam-
mation must be necessary for the healing of every wound; and then
there ceased to be any distinction between the union by the first inten-
tion and the imion by adhesion ; both alike seemed to be the result of
lymph, the product of inflammation, being exuded between the wounded
surfaces, and united to them both.
Typical examples of union by primary adhesion may be watched in
the cut edges of skin that are brought near together. When the cut
surfaces are not in exact contact, the wound is exposed, and lymph is
formed, and fills up the space ; or, when they are in contact, the sutures,
or other means employed to keep them so, excite inflammation enough
for the production of some lymph between them. The lymph is simply
laid on the cut surfaces ; and scarcely any is infiltrated in the tissues.
Organizing itself, and becoming vascidar, it connects the two edges or
• Works, VOL iii. p. 253.
186 HSALIKG BT PRIMARY ADnESIOlT.
surfaces, and, finally, forms between them a thin layer of cellular tissue,
on the thin surface of which, if it be exposed, a very delicate layer of
cuticle is developed. The smooth shining surface of this cuticle gives
the peculiar character of the scar, and one that scarcely changes, czcq>t
in the alteration of apparent color when the new material becomes less
vascular.
The lymph efiused in the healing by primary adhesion always, so far
as I know, developcs itself through nucleated cells, and, doubtless, the
whole process is very similar to that of the adhesion of inflamed serous
membranes.
It may be very quickly accomplished. A boy died eighty hours after
receiving a lacerated wound of the abdomen ; and, for forty-eight hours,
of these eighty, he was so manifestly dying, that I think no reparative
process could have been going on. A portion of the edges of the wound
was united with lymph, which presented well-marked cells, like those of
granulations, and contained looped bloodvessels full of blood.
But it may be accomplished more quickly than in this case. In a
rabbit that I operated on as for hare-lip, I found, after forty-eight hours,
the edges of the wounds partially, but firmly, united by lymph, many of
the cells of which were already elongated, in such development as I have
already described. Or, even more quickly than in this instance : — ^if a
small abscess be opened, and the edges of the opening are not gaping or
inverted, they may be found united, except at the middle, within twenty-
four hours. I have seen them so united, with a distinct layer of soft,
pinkish, new substance, in a wound made seventeen hours previously.
There are no cases in which the process of primary adhesion can be
better observed than after operations for hare-lip. The inner portions of
the wounds made in them may be healed by the immediate union, when
the surfaces have been in exact coaptation ; but the edges of the skin
and mucous membrane seem always united by the adhesive inflammation,
for a scar is always visible — a scar formed by the lymph organized into
cellular tissue and epithelium, and one which, as well as any, shows how
little of assimilative force can be exercised by adjacent tissues ; for,
narrow as it may be, it does not become quite like the adjacent skin, nor,
like it, bear perfect epidermis and hair.
The history of union by primary adhesion cannot be conveniently
completed till an account has been given of the healing by granulation
and by secondary adhesion. Of these I will next speak : now I will only
say of this union by primary adhesion, that it is less desirable than the
immediate union, because, 1st, it is, probably, not generally so speedy ;
2dly, it is not so close, and a scar is always formed by the organization
of the new matter ; and, 3dly, the formation of lymph- or exudation-
cells is a process so indefinitely separated from that of the formation of
pus-cells, that union by primary adhesion is much more likely to pass into
suppuration than any process is in which no lymph is formed.
HEALIKO BY GRANULATION. 187
In describing the modes of healing by granulation and by Bteondary
«i2Aei»on, I shall yentore again to take my accoont from certain typical
examples : such as cases in which, after amputation of a limb, the sur-
fiuses of the wound are not united by either of the means already
described, but, as the expression is, are ^^ left to granulate ;" or such
eases as the removal of a breast, and subsequent suppuration of the flaps
and die exposed fascia ; or such as wounds into inflamed parts, when the
edges gape wide asunder, and the spaces left between them are filled up
with granulations. These may serve as examples of a process which,
although in all cases it may preserve certain general features of simi-
larity, is yet in detail almost infinitely diversified, and often so inexpli-
cably, that any more than a general account of it might fill volumes."^
Ghranulations will generally arise on all wounded surfaces that are left
open to the air and are not allowed to dry. They will do so whether this
exposure be continued from the first infliction of the wound, or commence
after the edges, which have been brought together, have been again
forced asunder by the swelling of the deeper-seated parts, or by hemor-
rhage, or secretion of fluid, between them. Exposure of a wound to the
air is not prevented by any ordinary dressings : the air that is enclosed
beneath them, or that can penetrate them, appears to be quite enough to
determine all the difference of the events that follow open and subcuta-
neous injuries.
The simplest case for illustration is that of an open gaping incised
wound, which, from the time of its infliction, is only covered, as in ordi-
nary practice, with water-dressing, or some soft and moist substance.
Blood gradually ceasing to flow from the surface of such a wound, one
may see still some blood-tinged serous-looking fluid oozing from it.
Slowly, as this becomes paler, some of it collects, like a whitish film or
glazing, on the surface ; and this, if it be examined with the microscope,
will be found to contain an abundance of the white corpuscles of the
blood, imbedded apparently in a fibrinous film. The collection of these
corpuscles on the surface of the wound, especially on wounded muscles
and fasciae, appears to depend only on their peculiar adhesiveness. One
sees them adhering much more firmly than ever the red corpuscles do to
the walls of the minute bloodvessels, and to the glass on which they are
examined ; and so on cut surfaces, while the other constituents of the
blood flow away, the white corpuscles, and, probably, also, some of the
fibrine quickly coagulating, adhere.f
• Some of ilie most importaat modifications of tlie process occur in gim-shot wounds.
These are admirably described bjr Mr. Guthrie in the Lancet, Feb. 14, 1852.
t Rcinliardt, by whom, I think, the fact was first clearly noticed (Traube's Beitrage, H.
iL p. 188), supposes the white corpuscles may exude separately from the vessels. Perhaps
the truth is, that their peculiar adhesiveness makes them flow less readily from the blood-
vessels, when the bleeding is about to stop ; so that at last, when the vessels finally close
and empty themselves, a large proportion of these corpuscles may issue from them and
adhere to the cut surface over which they slowly roll.
188 HEALING BY GRANULATIOIT.
I am not aware of any facts that would prove what share the white
corpuscles thus collected may take in the healing of a wound. They do
not hinder it ; for it is by many believed to be favorable to union by
primary adhesion, to leave cut surfaces exposed, till they appear glaied
over with the whitish film, and then to put them into contact. It is pro*
bable the corpuscles are organized when the surfaces that they cover are
brought together : but I know of no facts bearing on the point, and it is
one which I think experiments on animals could hardly be made to
illustrate.
If a wound be left open, the glazing remains on such parts aa it may
have formed on, especially on the exposed muscles. No evident change
ensues in it, except that it appears to increase slowly, and makes the
surface of the wound look as if covered with a thin grayish or yellowish*
white layer of bufiy coat. This increase of glazing is the prelude of the
formation of granulations ; but while it is going on, and, often, for some
days later, there is, in and about the wound, an appearance of complete
inaction ; a calm, in which scarcely anything appears except a slight
oozing of serous fluid from the wound. Such a calm continues from one day
to eight, ten, or more, according to the nature and extent of the wounded
part, and the general condition of the body. In a cut or sawn hard
bone, about ten days will generally elapse before any change is manifest ;
in cancellous bone the change ensues a few days more speedily : on the
under surface of a large flap of skin, with subcutaneous fat, three days
may thus pass without change ; on the cut or excoriated surface of the
more vascular part of the skin, two days or three.
These periods of repose after severe injury are of equal interest in
physiology and in surgery ; but in the former it is chiefly the interest of
mystery. Observations on injuries of the frog's web* make it probable
that the blood is stagnant in the vessels for some little distance from the
woimd during several days after the injury : but why it is so, and what
are the changes ensuing in and about it, preparatory to its again moving
on, we cannot quite tell. The interest to the surgeon watching this
period of repose is more practical. The calm may be the brooding-tinie
for either good or evil ; whilst it lasts, the mode of union of the wound
will, in many cases, be determined : the healing may be perfected, or a
slow 'uncertain process of repair may be but just begun ; and the mutual
influence, which the injury and .the patient's constitution are to exercise on
one another, appears to be manifested very often at or near the end of
this period. Moreover, in open wounds, the time at which, on each tissue,
granulations are produced, is determined by this calm ; for they begin to
be distinctly formed at its end. Thus, on a stump, after a circular
amputation, one may find the margin of the skin and the surface of the
* See especially those detailed by Mr. Travers in his Essay on Inflammation and the
Healing Process : and those by Mr. Wharton Jones, On the State of the Blood and Blood-
vessels in Inflammation.
HBALING BY GBAKULATION. 189
moieles well covered with granulfttions, while the surface of the fat re-
fleeted with the skill is barren of them^ and the sawn walls of the bone
an dry and bare. But from the sawn end of the medullary tube there
may already protrude a florid, mushroom-shaped mass of granulations,
oferhanging the adjacent walls : as if parts in which nutrition is habi«
toally carried on under restraint, within hard and rigid boundary-walls,
were peculiarly apt to produce abundant organizable material as soon as
they are released.* Generally, also, the granulations springing from
Aeee different tissues obsenre the same order in their rate of development
It in their first appearance. Those that first take the lead keep it, or
for a time increase it.
But suppose the period of calm after the violence of the injury to be
well over-past — ^how does the right process of repair set in ? Apparently,
first of all, by the supply of blood to the injured part being increased.
The experiments on the webs of frogs, to which I have already referred,
have shown that, immediately after the infliction of an injury, the blood
in the adjacent parts remains for some days quite stagnant ; and we may
bdieve the same occurs, but for a shorter time, in our own case. During
this stagnation, materials may ooze from the vessels, enough to form the
glaiing of the wounded surfaces of certain parts ; but before granulations
can be formed, the flow of blood must again begin, and its supply must
be increased by enlargement, and perhaps by multiplication, of the vessels
in the injured part. We cannot often see this increase so well in soft
parts as in bone exposed after injury. If, in this condition, compact
bone be watched, there may be seen, two or three days before the
sprin^g up of granulations, rosy points or minute blotches, which gra-
dually deepen in their hue, and become larger. From these, presently,
granulations will arise. The same process may be well seen when a por-
tion of the skull has been exposed, as by suppuration under the pericra-
nium. In such a case, which I watched carefully, nearly one-third of
the upper part of the skull was bared, and it became dry and yellowish,
and looked quite lifeless ; but after some days a few rosy points appeared
on its surface, and these multiplied and enlarged, and from each of them
granulations grew up, till the whole surface of the skull was covered. I
watched them nearly every day, and it seemed evident, at least to the
naked eye, that, in all cases, an increased supply of blood preceded the '
production of the new material from which granulations were to be
formed.
Doubtless just the same happens in soft parts as in bone ; so that it
may be stated, generally, that the first visible change that ensues after
the period of calm — the period of incubation, as it is called — is an in-
• One may sometimes obsenre a similar fact in the growth of granulations out of the very
centre of the cut end of a divided tendon, while its margins are unchanged. Tlic abundant
growth of substance like brain covered with granulations, in cases of hernia cerebri is of
the Mmfie kind.
140 HBALING BT GRAKULATIOK.
Qreased supply of blood to the parts in which repair is to ensne. This,
probably, corresponds exactly with the increased afflux of blood which
ensues in inflammation ; and Mr. Travers's and other obsenrations on the
healing of the frog's web, make it nearly sure that this increased afflux
is attended with slower movement of the blood, or at first even with stag-
nation of the blood in the minute vessels nearest to the cut edges <»r
surface.
Of the force by which this increased afflux of blood is determined, I
believe that as yet no sufficient explanation can be rendered ; but the fact
serves to show that the ordinary process of granulation is, in its com-
mencement, morbid. It is beneficial, indeed, in its end or purpose, but
is morbid in its method, being comparable with the process of inflamma-
tion more than with any of those that are natural to the body. The
process of granulating displays, I think, two points of resemblance to
inflammation, and of dissimilarity from natural processes : namely, Ist,
that the increased quantity of blood in the part producing granulations,
moves more slowly than in health; while in the naturally^increased
supply its movement is not retarded ; and 2dly, that the increased supply
of blood precedes the increased production of material. For, in the dis-
charge of natural functions, the increased supply of blood to a part
appears always to be a secondary event, the consequence of some increase
in the formation of the part. As, in the embryo, many parts form them-
selves before blood appears, and the growth of these and other parts always
a little precedes the proportionate supply of blood to them ; so always,
subsequently, the increase or diminution of growth, or any other organic
act, appears to precede, by some small interval, the proportioned change
in the supply of blood. But with unnatural and morbid processes it
appears to be usually diSerent; in these, with inflammation for their
typo and chief example, the increased afflux of blood precedes the in-
creased production of material to be organized, and the decrease of blood
precedes the decrease of organic processes.
That which next follows, after the increased afflux of blood, is the
efiusion of the material that is to be organized into granulations. This
is added to, or, perhaps, displaces, the glazing that already exists upon
some surfaces ; and where none such exists, as on fat or bone, the new
material is accumulated on the bare surface of the wound. No account
of the process of effusion, so far as it is visible to the naked eye, can be
better than Mr. Hunter's (iii. 491). " I have often been able," he says,
" to trace the growth and vascularity of this new substance. I have seen
upon a sore a white substance, exactly similar, in every visible respect,
to coagulating lymph. I have not attempted to wipe it off, and the next
day of dressing I have found this very substance vascular ; for by wiping or
touching it with a probe, it has bled freely. I have observed the same ap-
pearance on the surface of a bone that was laid bare. I once scraped off
HBALINO BT GRANULATION. 141
Bonie of the external surface of a bone of the foot, to see if the surface
vMild granulate. I remarked, the following day, that the surface of the
bone was covered with a whitish substance, having a tinge of blue ; when
I passed my probe into it, I did not feel the bone bare, but only its resis-
tance. I conceived this substance to be coagulating lymph thrown out
from inflammation, and that it would be forced off when suppuration
came on ; but, on the succeeding day, I found it vascular, and appearing
like healthy granulations."
To this account, little can be added more than the microscope has
shown. In the minute structure of granulations, or, at least, of such
growths of new substance as present all the characters that we imply by
that term — ^the bright ruddy texture, the uniformly granulated free sur-
face, the sncculency and abundant supply of blood — in these we may
discenf two varieties, corresponding with the varieties of lymph that I
have already spoken of. In subcutaneous injuries or diseases, granula-
tions sometimes form which develope themselves into ^cellular tissue,
through nucleated blastema. So I foimd in a case of simple fracture in
which the ends of the bone remained long disunited ; they were enclosed
in a cavity formed by condensation of the surrounding tissues, but con-
taining no pus, and were covered with a distinct layer of florid granula-
tions. It was just such a case as that which Mr. Hunter had in view,
and preserved,* as an instance of the formation of granulations without
suppuration, in the repair of subcutaneous fractures and other injuries.
But in by far the greater proportion of cases, granulations are only
formed in exposed injuries : and in these, they consist of cells that may
develope themselves into fibro-cellular tissue : and of such as these I will
now exclusively speak.
Cells upon cells, such as I have already described (p. 183), are heaped
up together in a layer from half a line to two lines, or, rarely, more in
thickness, without apparent order, and connected by very little inter-
mediate substance (Figs. 14 and 19). Singly, they are colorless ; but in *
clusters they are ruddy, even independent of the bloodvessels. In granu-
lations that are making healthy progress — in such as, after three or four
days' growth, are florid, moist, level, scarcely raised above the surround-
ing tissues, uniformly granular, or like a surface of minute papillae— one
can conveniently trace the cells in various stages, according to the posi-
tion they occupy. The deeper-seated ones are always most advanced,
and often much elongated, or nearly filamentous ; while the superficial
ones are still in a rudimental state, or, near the edges of the granulating
surface, are acquiring the character of epithelial cells.
The cellular tissue thus constructed by the development of the granu-
lation-cells finally assumes all the characters of the natural examples of
that tissue. Thus it is found in the thin layer of substance of which
scars that are formed in the place of granulating wounds, are composed.
* College Museum, No. IC.
142 HEALING BT GBANULATIOX.
After some time, elastic tissue is mingled with the fibro^cellnlar ; but this,
as I have already said, appears to be eflfected by a later process. I foimd,
in one case, no elastic tissne in scars that had existed, the one twelfe
months, the other eighteen months ; but in scars several years old I have
always found it.
The cuticle, also, that forms on granulations, gradually approzimatei
more nearly to the perfect characters, and, like the fibro-cellular tissue
that it covers, presents the interesting fact of adaptation to the purpoiei
of the part on which it is placed. Thus, in granulating wounds or ulcen
on the sole of the foot, one may often see that, from the first, the new
cuticle is more opaque and thicker than it is on other parts, on whidi
the natural cuticle, in adaptation to the protection required from it, is
naturally thinner : and let it be observed that this peculiar formation of
the new cuticle is in adaptation to conditions not yet entered upon.
It justly excited the admiration of Albinus,"^ when he saw in the foetus,
even long before birth, the cuticle of the heel and palm thicker than
those of other parts ; adapted and designed to that greater friction and
pressure to which, in future time, they would be exposed. It is the
same when, in adult life, new cuticle is to be formed on the same parte.
While it is forming, all pressure and all friction are kept away, yet it is
constructed in adaptation to its future exposure to them. Surely such
a provision is, beyond all refutation, an evidence of design ; and Burely
in this fact we may discern another instance of the identity in nature
and in method of the powers that are put in operation in the acts of
first construction and of repair.
But before I end this lecture, let me add, that although one may so
clearly trace in the development of granulation-cells, and in the end
which they achieve by the formation of fibro-cellular tissue and cuticle,
an imitation of the natural processes and purpose of the corresponding
developments in the embryo, yet is there a remarkable contrast between
them, in regard to the degrees in which they are severally liable to
defect or error. We can scarcely find examples of the arrests or errors
of development of mere structure in the embryo ; but such events are
quite common in the formation of granulations, as well as of all other
new products. All the varieties in the aspect of granulating wounds and
sores, which the practised eye can recognise as signs of deflection from
the right way to healing, are so many instances of different diseases of
the granulation-substance ; diseases not yet enough investigated, though
of much interest in the study of both the healing process and the organi-
zation of new products in inflammation.
A comparatively few observations enable one to trace morbid condi-
tions of these new structures, closely answering to those long known in
the older and more perfect tissues. Thus, one may find simply arrested
development of granulations ; as in the indolent healing of wounds and
* Annotationes Academicae.
VOBXATION Of NBW BLOODVESSELS. 148
nloers, whether from locaUy or generally defective conditions. Herein
even years may pass, and the cells will not develope themselves beyond
one or other of their lower forms. There is probably a continual muta-
tion of particles among such cells, as in common nutrition; or they
may increase, as in growth ; but no development ensues, and the wound
or the ulcer remains unhealed.
In other cases, the cells not only do not develope themselves, but they
degenerate, becoming more granular, losing the well-marked characters
of their nucleusi and acquiring all the structures of the pus-cell ; thus
are they found in the walls of fistulsB and sinuses. Or, worse than this,
the granulation-cells may lose all structure, and degenerate into a mere
layer of debris and molecular substance. Thus they may be found on
the surface of a wound for a day or so before death or exhaustion, or in
erysipelas, or fever ; and in this state they are commonly ejected when
a granulating wound ulcerates or sloughs.
With more active disease, granulations become turgid with blood, or
oedematous : such are the spongy masses that protrude beyond the
openings leading to diseased bone. Or, they inflame; and abundant
large inflammatory granule-cells are found among their proper struc-
tures. Or, they suppurate internally, and purulent infiltration pervades
their whole mass.
AH these are among the many hindrances to healing : these are the
dangers to which the healing by granulations is obnoxious; it is the
proneness to these things that makes it even slower and more insecure
than, in its proper course, it might be. And these are all instances of
a class of changes which it is most important to study for exactness
in morbid anatomy, — I mean the diseases of the products of disease.
LECTURE X.
THE PROCESSES OF REPAIR OF WOUNDS.
With the structural development of the granulation-cells into fibro-
cellular tissue and cuticle, as described in the last lecture, there coincides
a chemical change which seems to be the contrary of development ; for
the granulation-substance being converted from albuminous into homy
and gelatinous principles, becomes, in chemical composition, less remote
than it was from the constitution of inorganic matter. At its first eflfu-
sion, the reparative material has the characters of a fibrinous principle ;
afterwards, when in the (brm of granulations and of young fibro-cellular
tissue, its reactions are so far altered that it presents the characters of
144 FOBIIATION OF NBW BLOODVESSELS.
pyinc, a somewhat indefinite principle, yet an albuminons one ; finally,
in its perfect development, the new-formed fibro-cellular tissue is gela-
tinous, and the epithelium appears to be like other specimens of homy
matter.
These changes are in conformity with what appears to be a general
rule ; namely, that structures which are engaged in enegretic develop-
ment, self-multiplying, the seat of active vital changes, are generally of
the highest organic composition ; while the structures that are already
perfect, and engaged in the discharge of functions such as are attended
with infrequent changes of their particles, are as generally of lower
composition. The much higher chemical development (if I may so call
it) of the blood, than of the greater part of the tissues that are formed
from it, is a general instance of this : in it albumen and fibrine predomi-
nate, and there is no gelatine: in the tissues gelatine is abundant, and
fatty matter ; and both these, through their afiinities to the saccharine
and oily principles, approach the characters of the lower vegetable and
inorganic compounds.
The granulation-substance is a good instance in point : while lowly
developed, but in an active vegetative life, it is albuminous ; when perfect
in its development, its perfected structures are gelatinous or homy. In
this state its particles have probably a longer existence : they exchange
a brief life of eminence for longevity in a lower station.
I have spoken hitherto of the development of only those structures
which form the proper material of granulations, and of the scars that
remain after the healing of wounds. But, commcnsurately with these,
bloodvessels, and, perhaps, also, nerves, are formed. Of these, therefore,
I will now speak.
In the last lecture I referred to the changes that ensue in the circula-
tion of a wounded part. At first, it appears that the blood stagnates in
the vessels immediately adjacent to the wound. This is evident in the
wounds made in frogs* webs, and is most probable in the case of wounds
in our own tissues ; for else we could hardly understand the total absence
of bleeding from a surface on which, as in every large wound, myriads
of small vessels must be cut, and lie exposed. But after a time, of
various duration in the difierent tissues, the movement of the blood is
renewed, though not to its former velocity ; the vessels of the wounded
parts enlarge, and they all appear more vascular. Then the material
of granulations, already in part effused, accumulates, and very soon
blood and bloodvessels appear in this material.
By what process are these new vessels formed? Mr. Hunter's opinion
was (and it is still held by many), that both the blood and its vessels
form in the gi-anulation-substancc, as they do in the germinal area of
the chick ; and that, subsequently, they enter jnto communications with
the vessels and blood of the part from which the granulations spring.
VOBMATION OF HEW BLO OBVESSBLS. 145
This is certainly not proved; although the development of the new
vessels is according to a method that is equally natural.
In embryos, we may discern three several modes according to which
bloodvessels are formed, — a good example of the manifold ways by
which, in development, the same end may be reached.* In the first
and earliest method, they are constructed around the blood corpuscles,
which, being gradually developed from some of the embryo-cells, are
laid out in the plan of the earliest and simplest circulation of the blood.
In this case, the vessels appear to be formed of the cells, or of the
plasma which lies around the forming blood-cells, and gradually assumes
the condition of a membrane, and is then developed into the more com-
plex structures of the bloodvessels and the heart.
After this earliest period of embryo-life, it is probable that blood is
never formed except within the vessels already constructed. It would
seem as if none but the original embryo- or germ-cells could be directly
transformed into blood-corpuscles ; all those that are later made derive
their materials through a process of gradual elaboration in lymph- or
bloodvessels, to which process no resemblance can be discerned in the
substance of granulations.
To increase the extent and number of vessels that must be added in
adaptation to the enlargement and increasing complexity of the embryo,
two methods are observed. In one, primary cells, in the interspaces of
vessels already existing, enlarge and elongate, and send out branches
in two or more directions. These branches are hollow : and while some
of them are directed into anastomosis with each other, others extend
towards, and open with dilatations into the vessels already formed and
carrying blood. Then, these fine branches of each cell becoming larger,
whfle the main cavity of the cell, from which they issued, attenuates
itself, they are altogether transformed into a network of tubes of nearly
uniform calibre, through which the blood, entering by the openings of
communication with the older vessels, makes its way. Thus the wide
network formed in the primordial circulation is subdivided into smaller
meshes, and each part receives a more abundant supply of blood.
The other of these secondary modes of formation of new bloodvessels,
is, I believe, the only mode in which bloodvessels are ever formed for
granulations, or for superficial deposits of lymph, adhesions, and the
like. The sketch is made from what may be seen in the growing parts
of the tadpole's tail, and it accords with what Spallanzani observed of
the extension of vessels into the substance of the tail when being repro-
duced, after excision. Mr. Traversf and Mr. Quekett watched the same
* They sre deacribed in Kirke's Physiology, p. 6G1 ; and in the Supplement to the Trans-
lation of MuUer's Physiology, p. 101. See also Garlach ; Gewebelehre, p. 200.
t On Inflammation, and the Healing Process. See, also, on a similar formation, Virchow,
in the WUnUarg Yerhandlungen, B. i., p. 301.
10
146
FORMATION OF NEW BLOODYESSBLS.
¥ig.ie.
process in the new material formed for the filling up of holes made in
the frog*s web ; and the same is indicated in the specimens illustrating
the repair of similar womids which are in the College, from the Mnsemn
of the late Dr. Todd, of Brighton. There is, I think, no snffident reason
to suppose that any other method prevails for the supply of bloodyeflsels
to any granulations, or similar new productions. For, though the pro-
cess in granulations or in lymph cannot be exactly watched during life,
yet every appearance after death is consistent with the belief that it is
the same as has been traced in the cases I have cited, and I have never
seen any indications of either of the other methods of development having
occurred.
The method may be termed that by outgrowth from the vessels
already formed. Suppose a line or arch of capillary vessels passing
below the edge or surface
of a part to which new mate-
rial has been superadded.
(Fig. 16.) The vessel wiD
first present a dilatation at
one point, and coincidently,
or shortly after, at another,
as if its wall yielded a little
near the edge or surface.
The slight pouches thus
formed gradually extend, as
blind canals or diverticula,
from the original vessel, still directing their course towards the edge
or surface of the new material, and crowded with blood-corpuscles, which
are pushed into them from the main stream. Still extending, they con-
verge ; they meet ; the partition-wall, that is at first formed by the meet-
ing of their closed ends, clears away, and a perfect arched tube is
formed, through which the blood, diverging from the main or former
stream and then rejoining it, may be continuously propelled.
In this way, then, are the simplest bloodvessels of granulations and
the like outgrowths formed. The plan on which they are arranged i&
made more complex by the similar outgrowths of branches from adjacent
arches, and their mutual anastomoses ; but, to all appearance, the whole
process is one of outgrowth and development from vessels already formed.
And I beg of you to consider the wonder of such a process ; how, in a
day, a hundred or more of such loops of fine membranous tube, less than
1-lOOOth of an inch in diameter, can be upraised ; not by any mere
force of pressure, though with all the regularity of the simplest mecha-
nism, but each by a living growth and development, as orderly and exact
as that which we might trace in the part most essential to the continuance
of life. Observe, that no force so simple as even that of mere extension
or assimilation can determine such a result as this : for, to achieve the
FOBMATION OF NEW BL00DVB88BL8. 147
ooDStmction of such an arch, it must spring with due adjustment from
two determined points, and then its flanks must he commensuratelj
raised, and these, as with mutual attraction, must approach and meet
exactly in the crown. Nothing could accomplish such a result but forces
determining the concurrent development of the two outgrowing vessels.
We admire the intellect of the engineer, who, after years of laborious
thought, with all the appliances of weight and measure and appropriate
material, can begin at points wide apart, and force through the solid
masses of the earth one tunnel, and can wall it in secure from external
violence, and strong to bear some ponderous traffic ; and yet he docs but
grossly and imperfectly imitate the Divine work of living mechanism
that is hourly accomplished in the bodies of the least conspicuous objects
of creation — nay, even in the healing of our casual wounds and sores.
The wonder of the process is, perhaps, in some degree enhanced by
the events that will follow what may seem to be an accident. When the
new vessel has begun to pro-
ject, it sometimes bursts ; and ^' ^^'
the diagram shows what then
will happen. I have to thank
Mr. Quekett for the sketch,
which he made while assisting
Mr. Travers in the examina-
tions already cited. The
blood-corpuscles that issue
from the ruptured pouch or diverticulum collect in an uncertain mass
within the tissue, like a mere ecchymosis ; but, before long, they mani-
fest a definite direction, and the cluster bends towards the line in which
the new vessel might have formed, and thus opens into the other portion
of the arch, or into some adjacent vessel. For this mode of formation
from vessels, the name of channelling seems more appropriate than that
of outgrowth ; for it appears certain that the blood-corpuscles here make
their way in the parenchyma of the tissue, unconfined by membranous
walls. That they do so in a definite and purposive manner, though their
first issue from the vessel has appeared so accidental, may be due to the
fact that in the more regular development by outgrowth, the cells of the
parenchyma concur with the extension of the new vessels, by clearing
away from them as they approach ; so that, even before the outgrowth,
the way for it, or for its contents (should they happen to escape), is, in
some measure, determined.
The occurrence of such a process of channelling as is here indicated,
loses all improbability, when we remember that in many insects and
mollusca the blood habitually flows, in a considerable and important
part of its course, through lacunae, spaces, or channels without proper
walls, such as are here supposed to exist only for a time.
148 FOKMATIOK Ot SXV BLO0DVEBSBL8.
The general plan of arraDgemeut of the bloodvessela in granula-
tions, represented in the adjoining
sketch, agrees with this account
of their development by outgrowth.
*S^l ^ ]ini \J^^My/ ^°™^ *'^ ^^ ^' ^°°'P^'^ prepara-
(iSii^ a )V ^{(/r)l t'O'^^ "1 t^^ Muaemn of the Col-
,■^=^4 }^Ui ar^k.Jr II (f^^\ lege* show how the new vesBels
extend from the parts on which the
granolations lie, in lines directed
vertically towards their gnr&ce,
not often dividing, but comnmni-
oating on their way by frequent
transverse or irregular branches.
Of these branches, some, probably,
represent the loops or arches suc-
cessively formed in the deepening
layer of granulation-cells, white
oUiers must be formed by ofihoots
from the sides and other parts of the several arches. Near the bot-
face of the granulations, at a very little distance below the ontermoet
layer of the cells, the vessels communicate much more frequently, and
form their loops or terminal arches — arches of junction between the
outgoing and the returning streams of blood.
On the same plan are formed the vessels of the walls of absceaaefi
lined with granulations ; but here (at least in the specimens I have been
able to examine) the vertical vessels are not so long, and the whole num-
ber of vessels is generally greater. I beheve the vessels of granulating
ulcers are always similarly arranged; so they are represented by Hr.
Listonf in a common ulcer ; so, also, Sir A. Cooper^ described them in
granulations from an ulcerated scirrhous cancer ; and I have found the
same general plan in the warty ulceration of soot-cancer on the scrotiOD.
The structure of the new vessels formed Id granulations also agrees with
the described made of development. In the earliest period of their
appearance they present no indication of being formed by fusion, or any
transformation, of the granulation-cells, but consist of thin membrane, in
which, if it be not quite simple, nuclei or cytoblasts are imbedded.
These nuclei pass through stages of development, by narrowing asd
elongation, similar to that which I have described in the nucleated blas-
tema ; and thus they become like the pieces of flat fibre that one sees on
the walls of the original vessels of the same size. Like them, also, they
are arranged, some longitudinally, and some transversely to the axis of
the vessels ; and it is often noticeable, that the development of the tissaes
•Nos. IP.ao, 356.
t Medico-Chirui^iCHl Tranwctioni, vol. uiii. p. SS.
f Calali^ue oT the PatliologicBl Miueum of the College, toI. L p. 111.
VOBMATIOH OP HBV BLOOSTESSELS.
149
of the bloodressela makee more progresa tlian that of the grannlatioii-
eells which they Eabseire.
Beepecting the porpoee of the supply of blood thus sect to granula-
tioDs, one traces, in the development of vessels, a series of facta exactly
answeiing to those in ordinary embryonic development. Organization
m^es some progress before ever blood cornea to the very sabstance of
the growing part ; for the form of cells may be assomed before the gra-
nulations become vascular. But, for their continnons active growth and
development, fresh material from blood, and that brought close to them,
is essential. For this, the bloodveasela are formed ; and their size and
nomber appear always proportionate to the volume and rapidity of life
of the grannlationa. No instance would show the relation of blood to an
Bctdvely growing or developing part better than it is shown in one of the
vascnliu- loops of a granulation,
imbedded, as thia ahetch ahowa it,
among the crowd of living cells,
and muntaining their continual
mntstions. Nor is it in any caae
plains than in that of granula-
tions, that the supply of blood in a
part is proportionate to the activity
of its changes, and not to its mere
atmctoral development. The vas-
cular loops lie imbedded among the
simpleat primary cells, or, when
granolations degenerate, among
Btractorea of yet lower organiza-
tion ; and as the structures are de-
veloped, and fibro-cellnlar tissue
formed, so the bloodvessels become
kee numerous, and the whole of the new material assumes the paleness
and loT vascularity of a common scar. But, though the quantity of
bloodvessels is determined by the state of the aubatance they BUpply,-the
development of their tissues has no such relation. It is often complete
while the granulation-ceUs are rudimental, and remains long unchanged
when they are degenerate. The fact may be regarded as evidence of
4e formation of the new bloodvessela by outgrowth from the older ones;
for it is not probable that well-developed bloodvessels and ill-developed
granulation-cells should be formed out of the same materials at the aame
Of the development of Nerves in granulations I know nothing; I
have never been able to see any in either granulations or cicatrices. The
exquisite pain sometimes produced by touching granulationa would indicate
the presence of nerves : but it would be more satisfactory to see them ;
for the force of contact, or the change that it producee, may be '{jto^v
150 HBALINa BT SEGONDABT ADHESION.
gated through the layer of granulations, and stimulate the nerves beneath
them, as contact with the exterior of a tooth excites the nenre-filaments
in its pulp. The sensibility that granulations seem to have may, there-
fore, be really that of the tissues from which they spring.
Lymphatics do not exist in granulations. Professor Schroeder van
der Kolk has demonstrated them in false membranes by mercurial injec-
tions :* but in a letter he tells me that they cannot, either by these or
by any other means, be traced in either scars or granulations ; and, he
adds, ^^ they cannot be demonstrated in the skin, even in the healthy
state, except in the scrotum."
The subject of suppuration should perhaps be considered now ; but I
had rather defer it till I have spoken briefly of the two remaining modes
of healing open wounds ; those, namely, by secondart/ adhesianj and by
scabbinff.
The healing by secondary adhesion, or union of granulations, has
been long and often observed ; yet it has been only casually described,
and having never been distinguished by a specific name, has not received
that attention to which its importance in practice seems to entitle it. It
occurs wherever surfaces of granulations, formed in the manner just
described, well-developed, but not yet covered with cuticle, are brought
into contact, and so retained at rest. As often as this happens, the ceDs
of which the surfaces are composed adhere together; vessels passing
through them form mutual communications; and the surfaces, before
separate, are connected; out of the two layers of granulations, one is
formed, which pursues the normal development into fibro-cellular tissue.
In all its principal characters, therefore, the process of secondary
adhesion is like that adhesion for which, to mark at once their likeness
and their differences, I have suggested the term of primary. In the
primary adhesion, the layer of lymph, placed between the wounded and
bare surfaces, is probably formed equally and coincidently from both;
and, being developed in the same manner as the granulations, of which
I have spoken, it probably receives vessels from both surfaces, and so
becomes the medium through which the vessels communicate and combine
the severed parts. In the process of secondary adhesion, the superficial
cells on the surfaces of two layers of granulations are placed together,
and recei\'ing vessels from both combine them into one.
Mr. Hunter observed this process, and says of it — ^^Granulations
have the disposition to unite with one another when sound or healthy;
the great intention of which is to produce the union of parts, somewhat
similar to that by the first intention, although possibly not by the same
means." And " I have seen two granulations on the head — viz. : one
from the dura-mater after trepanning, and the other from the scalp —
* Lespinassc, De Vasis Novis Pseudo-membranarum, figs, iii., iv.
HBALIKO BY BBCOHDA&Y ADHBSIOK. 161
uiite over the bare bone which was between them so strongly, in twent j-
foor hours, that they required some force to separate them, and when
sqwrated they bled."*
In illustration of this process he pat up a preparationf which in his
MS. Catalogue he described as ^^granulations under the skin in an
abscess in the leg, which were opposed by others on the muscles, and
which were to unite. Those under the skin only are saved, and folded
towards each other, to show the opposition of two granulating surfaces."
There are several circumstances in which the healing by secondary
adhesion should be attempted. For example : after an ordinary ampu-
tation of the thigh, no immediate union, and no primary adhesion, took
place, and the whole interior of the stump was granidating. Had it
been, as the expression is, ^^ left to granulate," or ^^ to fill up with granu-
lations," the healing process would have occupied at least a month or
five weeks more, and would have greatly exhausted the patient, already
weakened by disease. But Mr. Stanley ordered the stump to be so
bandaged that the opposite surfaces of granulations might be brought
into dose contact : they united, and in a week the healing of the stump
was nearly perfected.
In all such cases, and I need not say that they are very frequent, the
heaJing by secondary adhesion may be attempted without danger, and
<xften with manifest advantage.
Again : Mr. Hunter operated for hare-lip, and no primary adhesion of
the cut surfaces ensued. He let them both granulate, then brought the
granulations together, as in the common operation, and they united, and
healed soundly.
Or, again : Mr. Skey, not long since, operated for fissure of the soft
palate. The edges of the woimds sloughed and retracted, and the case
seemed nearly hopeless ; but he kept in the sutures, and granulations
qirang up from the edges of the cleft, after the separation of the sloughs :
they met in the mid-space of the cleft, and coalesced, and formed a per-
fect scar.
Doubtless, cases like these are of no rare occurrence; but I am
induced to mention them, as illustrations of a process of which the
importance and utility are not generally considered, and which is rarely
applied in practice.
In applying it, certain conditions are essential to success ; especially
that — Ist, the granulations should be healthy, not inflamed, or profusely
suppurating, or degenerated, as those in sinuses commonly are ; 2dly,
the contact between them should be gentle,' but maintained ; and perhaps
they should be as much as possible of equal development and age.
The healing of wounds by scabbing may be regarded, as Mr. Hunter J
• Works, vol. iii. p. 493. t Pathological Muacum of the CoUege, No. 27.
X Works, VOL iU. 262.
152 HEALING UKDEB A SOAB.
says, as the natural one, for it requires no art. It is the method by
which one sees nearly all open wounds healed in animals ; for in them,
even in the warm-blooded, it is difficult to excite free suppuration from
the surfaces of wounds ; they quickly become coated with a scab, formed
of the fluids that ooze from them and entangle dust and other foreign
bodies ; and imder such a scab the scar is securely formed.
In general, the scabbing process is effected by some substance which is
effused on the surface of the wound, dries there, and forms a hard aod
nearly impermeable layer. The edges of this substance adhere over
those of the wound, so as to form for it a sort of air-tight covering
under which it heals without suppuration, and with the formation of a
scar, which is more nearly like the natural parts than any scars formed
in wounds that remain exposed to the air, and which does not, like them,
contract, so as to produce deformity of the parts about it.
The scab may be formed of either dried blood, dried lymph, and
serum, or dried purulent fluid. Instances of the healing of wounds under
dried blood are not rare. It is especially apt to occur in the cases of
wounds in which a large flat surface is exposed, as after the removal of
the breast with much integument. The most remarkable case of this
kind is recorded by Mr. Wardrop."*" The largest wounded surface he
ever saw, remaining after the removal of a diseased breast, almost
entirely healed under a crust of blood, which remained on for more than
thirty days.t But the most common examples of healing under blood-
scabs are in small wounds, such as are made in bleeding, or more rarely
in some compound fractures. The excellent, though nearly obsolete,
practice of laying on such wounds a pad of lint soaked in the blood, was
a good imitation of the most natural process of their repair.
If a blood-scab be not formed over a wound, or if such an one have
been detached after being formed, then at once a scab may be derived
from the serum and lymph that ooze from the surface of the wound.
Thus it is commonly with wounds in animals that are left to themselves,
and in many small wide-open wounds in our own case. Thus, also, I
imagine, the best healing of superficial bums and scalds is effected, when
the exposed surface is covered with cotton-wool or other substance, which,
as the oozing fluids become entangled with it, may help them to form a
scab.
At a yet later period, the pus produced from exposed granulating
wounds may concrete on them, and they will heal under it excluded firom
the air. Such a process may also ensue in the healing of ulcers, and
has been successfidly imitated in Mr. Stafford's plan of filling deep ulcers
with wax.| In any case, the healing process is probably just the same
• la his Lectures on Surgery, in the Lancet for 1832-3, vol. ii.
t Mr. Henry Lee tells me that a similar case has occurred in his practice. An excellent
instance of healing under blood-scabs is also related by Dr. Macartney (Treatise on Inflam-
mation, p. 208).
j: On the Treatment of the Deep and Excavated Ulcer. 1829.
HBALIKG UNDER A SCAB. 158
as that under scabs of blood or serum ; but I believe it has not yet been
exactly determined what are the changes that ensue in the surface
beneath the scab. So far as one can discern with the naked eye, the
wounded surface forms only a thin layer of cuticle on itself; no granu-
lations, no new fibro-cellular tissue, appears to be formed ; the raw sur-
fitoe merely skins oyer, and it seems to do so uniformly, not by the pro-
gressiye formation of cuticle from the circmnference towards the centre,
as is usual in open wounds.
The healing of a wound by scabbing has always been thought a desi-
rable process ; and when one sees how quickly, by means of this process,
wounds in animals are healed, and with how little general disturbance,
one may well wish that it could be systematically adopted. But to this
there seems some hindrance. Many surgeons have felt, as Mr. Hunter
did, that the scabbing process should be permitted much ofbener than it
IB, in the cases of both wounds and ulcers ; but none have been able to
lay down sufficient rules for the choice of the cases in which to permit it.
Probably, the reason of this is that, at the best, in the human subject,
the heaUng by scabbing is an uncertain process. When the scab is once
formed, and the wound covered in, it is necessary that no morbid exuda-
tion should take place. Whenever, therefore, inflammation ensues in a
wound or sore covered with a scab, the exuded fluid, collecting under the
scab, produces pain, compresses the wounded surface, or forces off the
scab, with discomfort to the patient and retardation of the healing. I
suspect that the many instances of disappointment from this cause have
led to the general neglect of the process of scabbing in the treatment of
wounds. The observance of perfect rest, and of the other means for
warding off inflammation, will, however, make it a valuable auxiliary in
the treatment of wounds, especially of large superficial ones : in the
treatment of small wounds, collodion appears sufficient to accomplish all
that scabbing would do ; and in deep wounds, fluid is too apt to collect
under the scab.
Such are the several methods of healing observed after wounds of soft
parts ;^ and in connexion with them, two subjects remain to be con-
sidered, namely, the process of suppuration, and that of the perfecting
of scars.
Respecting the process of suppuration, it cannot be necessary that I
should give a minute account of pus, or of its general or chemical cha-
racters : I will rather endeavor to show its relations to the healing pro-
* I have not been able to recognise what Dr. Macartney named the modelling proaUj as a
method of healing distinct from that which ensues in the most favorable instances of healing
hy grannlations. I have, therefore, not enumerated it among the modes of healing ; yet it
may occur in some conditions that I have not met with : I would not, wit# only my present
asperience, impute confusion to so good and independent an observer as Dr. Macartney.
154
SUPPUBATIOK.
cess, by illustrating' the points of resemblance and of difference between
it and the materials of which granulations are formed.
Let me remind you that the formation of granulations is not neces-
sarily attended with the production of pus. I have already referred to
this fact in speaking of the formation of subcutaneous granulations, such
as are sometimes seen on the end of bones that do not imite, in the
ordinary way, after simple fractures. Mr. Hunter also expressly de>
scribes these cases ; and the same kind of granulations without suppura-
tion may be sometimes seen springing from the ulcerated articular sur-
faces of bones, in cases of diseased joint without any external opening.
However, when gruiulations are formed on an open wound, there is
always suppuration ; ». e., an opaque, creamy, yellowish-white or green-
ish-white fluid, pus, or matter, is produced on the surface of the granu-
lations. If the surface be allowed to dry, the pus may form a scab : if
it be kept moist, fresh quantities of pus are produced, till the surface of
the granulations is covered with the new cuticle. Granulations that are
skinned over no longer suppurate.
The essential constituents of pus are cells, and the liquid {liquor puri$)
in which they are suspended. In pus produced during healthy granula-
tion, no other material than these may be foimd. But, often, minute
clear particles, not more than jjs^jfo of an inch in diameter, are mingled
with the pus-cells, to which they seem to have some relation as rudiments.
And when the process deviates from health, we find not only variations
in the pus-cells, but multiform mixtures of withered cells, molecular and
fatty matter, free or escaped and shrivelled nuclei, blood-corpuscles,
fragments of granular substance like shreds of fibrine, and other mate-
rials. All these indicate defects or diseases of pus, corresponding with
those of the granulations to which I have already referred.
Pus-cells, iu their ordinary state, are represented in the adjoining
sketch.
Fig. ao.
As shown at A, they are spherical, or spheroidal, or even discoid,
bodies, the differences in shape depending apparently on the density of
the fluid suspending them. In the same proportion as it becomes less
dense, they tend to assume the more perfectly spherical shape. They
have an uniform nebulous or grumous aspect ; distinct granules, more or
less numerous, are commonly seen in them; and they appear more
darkly nebulous and more granular in the same proportion as the fluid
becomes mor%den8e. Their usual diameter is from jj^^^ to jiijijf of an
inch. Sometimes a distinct, circular, dark-edged nucleus may be seen
BUPPUBATION. 166
in the paler corpuscles ; and, more rarely, two or even three particles
like a divided nucleus.
When, as in the corpuscles B, water is added to pus, it usually pene-
trates the cells, expanding them, raising up a distinct fine cell-wall, and
separating or diffusing their contents. Sometimes the contents are uni-
formly dispersed through the distended cell, which thus becomes more
lightly nebulous, or appears filled with a nearly clear substance in which
minute particles vibrate with molecular movement, while in or near the
centre a dark-edged well-defined nucleus may appear. Sometimes, while
the cell-wall is upraised, the whole contents of the cell subside into a
ungle ill-defined darkly nebulous mass, which remains attached to part
of the cell-wall, looking like a nucleus, but differing froiii a true nucleus
in the characters just assigned, as well as in the absence of the two or
three shining particles like nucleoli. Lastly, a few pus-corpuscles appear
unchanged by the action of water : they seem to be merely masses of
soft colorless substance having the shape and appearance, but not the
structure, of cells.
When dilute acetic acid is added to pus (as in Fig. G), it produces the
same effects as water, but more quickly, and with a more constant
appearance of two, three, or four small bodies like nuclei. These bodies
are remarkable, though far from characteristic, features of pus-cells.
They are darkly edged, usually flattened, clear, and grouped, as if
formed by the division of a single nucleus ; and commonly each of them
appears. darkly shaded at its centre. When the acetic acid has been too
little diluted, these bodies alone may be at first seen ; for the cell-wall
and the rest of its contents may be rendered so transparent as to be
scarcely visible.
Such are the pus-cells found in healthy suppurating wounds. The
liquor puris contains albumen, a compound called pyin, regarded by some
as identical with that which Mulder described as tritoxide of protein,
abundant fatty matter, and inorganic substances similar to those dis-
solved in the liquor sanguinis.
Pus not distinguishable from that of granulating wounds is formed in
many other conditions ; as in inflamed serous and mucous cavities, and
in abscesses. In these relations it will be considered in the lectures on
Inflammation. But the histories of all cases of the formation of pus
concur, with that of suppurating wounds, to the conclusion that pus may
be regarded as a rudimental substance ill-developed or degenerated ; as
a substance Essentially similar to the materials of granulations, or of the
lymph of inflammatory exudation, but which fails of being developed
like them, or, after having been developed like them to a certain stage,
degenerates.
To illustrate this relation between the pus and the granulations of
healing wounds, I may state that the last figure was copied from sketches
that I made, at the same time, of some granulation-cells from the walls
156 SUPPURATION.
of a sinus, and some pus-cells from a healthily granulating wound. I
chose those sources purposely, that I might be able to compare ill-deve-
loped granulation-cells with well-constructed pus-cells ; and a comparison
of them showed that, whether as seen without addition, or as changed by
the action of water and acetic acid, they were not to be distinguished
from one another. Had I not seen the yessels in the tissue that the
granulation-cells formed, I might, in the first examination, hare almost
thought I was deceived in thinking they were not pus-cells. The uz
varieties of the appearances of the cells which are represented might
have been taken from either source ; so might some other varieties : but
these may suffice to show the apparent identity of structure between
well-formed pus-cells and ill-developed or degenerate granulation-cellS|
such as are found in the walls of sinuses and the like half-morbid struc-
tures. I do not mean to say, generally, that granulation-cells and pus-
cells cannot be distingmshed ; for between well-formed granulation-cellSi
such as are found in healing wounds, and any particles that are usually
found in pus, certain distinctions are almost always manifest. The pus-
cells are darker, more and more darkly, granular, more various in sixe,
and more various, not in shape, but in apparent structure, more often
containing numerous particles, like fatty molecules, more rarely showing
a nucleus when neither water nor acetic acid is added, and much more
commonly showing a tripartite or ill-formed nucleus under the action of
the acid. None, however, of these characters is indicative of essential
difference ; and between even the widest extremes there are all possible
gradations, till distinction is impossible ; so that when you place, as I
have often done, ill-developed or degenerate granulation-cells on one side
of the microscope-field, and pus-cells on the other, there is not a form of
corpuscle on the one which is not repeated on the other.
From this, one cannot but conclude that the cells of pus from wounds
are ill-developed or degenerate granulation-cells. Some of them may be
degenerate, t. «., they may have been, as granulation-cells, attached for
a time to the surface of the granulation-layer, and having lived their
time, may, in ordinary course, have been detached and shed, as epithe-
lial cells are from healthy surfaces. They may be thus detached after
more or less degeneration, and hence may result some of the modifica-
tions that they present. But some pus-cells, I imagine (at least in the
healing of wounds), may be ill-developed ; that is, imperfectly Termed of
material which exudes from the surface of the granulations, and which,
being exposed to the air, or being too remote from the supply of blood,
cannot attain its due development, and, in an imperfctly developed state,
is soon cast off. It cannot but be that organizable matter is constantly
oozing from such a surface as that of granulations ; but the conditions
into which it enters on that surface are such as are very likely to hinder
any but the lowest or some imperfect organization.
The many characters of imperfection or of degeneracy that pus-cells
SUPPURATION. 157
&how, accord with this view : such as the general imperfection of their
nuclei ; the frequent abundance of fatty-looking granules in them ; the
large quantity of fatty matter that analysis detects in pus ; and the
limitation of the cells to certain forms, beyond which they are never
found developed, though none of these forms is more highly organized
than that of the youngest or most rudimental granulation-cell.
A further confirmation of the opinion that pus-cells are ill-developed
or d^enerate granulation-cells, is furnished in the cases, to which I shall
hereafter refer, in which pus-cells are produced after, or together with,
inflammatory lymph-cells ; as in abscesses, inflamed membranes, and the
like. Now such lymph-cells are not distinguishable in apparent struc-
ture from granulation-cells, and, like these, they may show every grada-
tion of form to that of the pus-cell.'*'
But it is not only in the cells that we may trace this appearance of
the degeneracy or incomplete development of pus. It is equally shown
in the fluid part, or liquor purisy which, unlike the intercellular substance
of granulations and inflammatory lymph, is incapable of organization,
even when, by evaporation or partial absorption, it assumes the solid
form. The liquor puris answers to the solid and organizable blastema
of granulations ; and as undue liquidity is among the most decided
marks of ill-formed pus, so the abundance of the blastema, in proportion
to the cells, is one of the best signs that granulations are capable of
quick development.
These considerations may suggest, in some cases, the imperfection of
the liquor puris ; and an observation, which any one may easily make,
seems to indicate that it may, in other cases, be the product of the de-
generation and liquefaction of the solid blastema, as the pus-cells are, in
the same cases, of the granulation- or inflammatory lymph-cells imbedded
in it. If the formation of abscesses be watched, one may see, on one
day, a large solid and inflamed swelling, firm and almost unyielding,
giving no indication of containing any collection of fluid ; but, next day,
one may detect in the same swelling the signs of suppuration ; the border
may feel as firm as before, but all the centre and the surface may be
occupied with an ounce or more of matter. And observe, this change
from the solid to the liquid state may have ensued without any increase
of the swelling. Such an increase must have occurred had the pus been
secreted in a fluid state into the centre of the solid mass: and the
changes cannot, I think, be explained except on the admission, that the
inflammatory product, which was effused and infiltrated through the
• Valentin, Gerber, and many others, have held nearly the same view as this of the
character of pas^ells *, but I think they have not sufficiently, if at all, dwelt on the proba-
bility that some pus-cells are ill-develoi>ed, others degenerate from a previously higher
development. The many varieties of form, and the many differences of the conditions in
which they occur, may be thus explained. I think, too, that the characters of degeneracy,
or imperfect development, in the liquor puris, have been too much overlooked.
158 BOARS.
tissue in a solid form, has been liquefied : its cells degenerating into pus-
cells, its blastema into liquor puris."*"
Can we assign any use or purpose to the process of suppuration 7 In
the case of abscesses and acute inflammations we may discern no more
of purpose than in any other disease. But, in the case of granulating
wounds, the use commonly assigned to pus, that it serves as a protection
to the granulations, is probably ascribed to it with reason. It does this
even in the fluid state ; but the devices of surgical treatment, having
regard to present comfort, rarely let us see how much better it protects
a wounded surface when, as in animals, it is allowed to dry into a scab.
Let us now consider the case of a wound completely healed, and the
scar that occupies its place.
It is hard to describe in general terms the characters of scars, varying
as they do in accordance with the peculiar positions, and -forms, and
modes of healing of wounds. But two things may be constantly ob-
served in them : namely, their contraction, and the gradual perfecting of
their tissues.
A process of contraction is always associated with the development of
granulations. Mr. Hunter has minutely described it, and preserved
several specimens to illustrate it: among which are two stumps,t in
which its occurrence is proved by the small size of the scars in compari-
son with that of the granulating surfaces which existed before them.
This healing of stumps, especially after circular amputations, will always
show the contraction of the granulations, even before the cicatrix is
formed ; for one sees the healthy skin drawn in and puckered over the
end of the stump, before any cuticle is formed on the granulationsy
except perhaps on the very margin. And many injuries, but especiaUy
bums, show the contraction of the scar continuing long after the appa*
rent healing is completed.
To what may we ascribe this contraction of both the granulations and
the scars ? It has been regarded as the result of some vital power of
contraction ; and possibly it may be so in some measure. Yet, on the
whole, it seems rather to be the necessary mechanical efiect of the
changes of form and construction that the parts undergo. The same
change ensues in the organization of inflammatory products: as, e.g,^
in false membranes, indurations, thickenings of parts, and the like con-
sequences of the exudation and organization of lymph.
Now, in all these cases, the form of the cell, while developing itself
into a filament, is so changed that it will occupy less space. The whole
• Such a liquefaction is not that assumed in the older doctrines, which held that pus was
partly formed of the dissolved materials of the original tissues. The original tissues donbl-
less remain, unless partially absorbed : yet there appears to be thus much of liquefaction in
the formation of an abscess, that part of the inflammatory product, first formed as a soft
solidf degenerates and becomes fluid.
t Nos. 28 and 29 in the Museum of the College.
SCARS. 159
mass of the deyeloping cells becomes more closely packed, and the tissue
that they form becomes much drier ; with this, also, there is much dimi-
nution of vascularitj. Thus, there results a considerable decrease of
balk in the new tissue as it developes itself; and this decrease, beginning
with the development of the granulation-cells, continues in the scar, and,
I think, sufficiently accounts for the contraction of both, without refer-
ring to any vital power.
The force with which the contraction is accomplished is often enor-
mous. One sees its result in the horrible deformities that follow the
healing of severe bums. Deep scarred and seamed depressions, even of
the bones, may be produced by the contraction of granulations and scars
over them. The whole process shows the error of such expressions as
^^ filling up with granulations," commonly applied to deep healing wounds,
as if granulations increased in thickness till they attained the level of the
upper nuurgins of deep hollows. The truth is, that, even in the deepest
open wounds, the granulation-layer is, as usual, from one to three lines
thick ; and that, when such a wound grows shallower in healing, it is not
by the rising of the granulations, but by the lowering of its margins.
The granulations and the scars of deep open wounds remain alike thin
and depressed.
The improvement and perfecting of the tissue of the scar is, again, a
very slow process. It is often thought remarkable that nerves and some
of the higher tissues should require so long time for their repair ; but
scarcely less is necessary for the perfecting of a common scar. The
principal changes by which it is accomplished include the removal of all
the rudimental textures, the formation of elastic tissue, the improvement
of the fibrous or fibro-cellular tissue, and of the new cuticle, till they are
almost exactly like thos^ of natural formation ; and the gradual loosen-
ing of the scar, so that it may move easily on the adjacent parts.
All these changes are very slowly accomplished. One sees their
effects, it may be, only after the many years in which, as it is said,
the scars of childhood gradually wear out ; t. e., in which the new-formed
tissues gradually acquire the exact similitude of the old ones. Thus, the
remains of the rudimental cellular tissue, imperfectly developed, may be
foimd in apparently healthy scars of ten months' duration. After
second operations, in which the scar of some former wound was removed,
I have still found imperfectly developed granulation-cells in the tissue of
the scar. Elastic tissue, also, I think, is not commonly formed in the
first construction of a scar, but appears in it sometimes as much as twelve
months after its first formation, and then gives it the common structure
of the mixed fibro-cellular and elastic tissues which exist in the cutis.
But, an occurrence which may appear more singular than this slow
perfecting of the tissues, is, in all good scars, as they are called, that
gradual loosening of the tissue which at first unites the scar to all the
160 REPAIR OF FRACTURES.
adjacent parts. Thus, in such a wound as is made for tying a deep
artery, or in lithotomy, at first the new tissue, the tissue of the scar,-
extends down to the bottom of the wound, equally dense in all parts, and
fastening the skin to the parts at the very deepest portion of the wound.
But after a time this clears up. The tissue of the scar in the skin
becomes more compact and more elastic ; but that beneath it becomes
looser and more like natural cellular tissue ; and the morbid adhesions of
one part to another are freed. So, after injuries or diseases followed by
scars about joints, the stiffness depending on the adhesion of the scar to
the deeper tissues gradually decreases : and, so, in like manner, the
scars of bums often become gradually and of themselves more pliant, and
the parts which they held become more freely movable, though some-
times scarcely seeming to change for a year after the first healing of the
injury.
Now, in all this gradual return of tissues to the healthy state, we may
trace, I think, a visible illustration of the recovery from the minute
changes of disease. In all there is a gradual approach of the new par-
ticles that are successively produced, to a nearer conformity with the
specific character of the parts they should replace, till repair becomes
almost reproduction. And how, let me ask, can all this be reconciled
wiiih any theory of assimilation ? How can assimilation alter the charac-
ters of a scar ? how make one part of it assume one character, and another
part a character quite different, till, at length, that which looked homo-
geneous, as a mass of new-formed tissue, acquires, in separate parts, the
characters of the several tissues in whose place it lies, and whose office it
is destined, though still defectively, to discharge ?
LECTURE XL
THE REPAIR OF FRACTURES.
The necessity, which I have felt in the preceding lectures, of describing
the healing process as it is observed in a few typical examples, is in-
creased, when I come to the consideration of the repair of fractures. A
volume would not suffice for all that should be said of it ; for there are
no examples of the reparative process which present so many features of
interest as this docs, whether we consider its practical importance, or the
wide field which it offers alike for the science and for the art of surgery,
or the abundant illustrations of the general principles of recovery from
injury which are present in every stage of the process, or the perfect
evidences of design which it displays, of design that seems unlimited in
the variety and point with which it is adapted to all the possible diversi-
BEPAIB OF FRACTURES. 161
ties of accident. To consider the repair of fractures completely, in any
of these yiews, would be far beyond my purpose, and farther beyond my
tbility. I shall therefore limit myself almost entirely to an account of
the repair of the simple fractures of long bones. What is true of this
irin be so nearly true of the repairs of other fractures, that a few words
may Buffioe in reference to the chief modifications of the process in them.
Moreoyer, I shall in general describe only what occurs in the adult
Imnian subject.
The injury inflicted in the fracture of a long bone is rarely limited to
the bone. The two or more fragments, driven in opposite directions,
penetrate the adjacent tissues, wounding and bruising them, and giving
rise to bleeding of various amount. Provided all these injuries are sub-
cutaneous, and the air has no access to the damaged parts, their repair
is perfectly, though slowly, effected. It is not unfrequent, in recent
frsctures, to find portions of muscle or other soft parts completely crushed
by the bones, or even, in minute fragments, enclosed in the reparative
■aterial or the inflammatory exudations ; and yet, when similar fractures
are examined a year or more after their occurrence, the tissues round the
bone appear quite normal in their structure, however disturbed they may
be in their relations.
Hie periosteum is rarely much damaged in fractures of long bones.
It is seldom stripped off" the broken ends. Commonly, it is cleanly rent
lerosB at the same level as the bone is broken, and maintains its close
union, having only its fibres somewhat frayed or pulled from their natural
direction. Sometimes, indeed, it remains entire, even in extensive frac-
tures ; and in this case, thickening, it contributes to the security of the
repair of the injury.
The extravasation of blood about fractures is not only uncertain in
amount, but unequal in the several tissues. Its abundance in the sub-
cutaneous tissue is often so remarkable, as to be among the useful signs
tcft diagnosis, in cases of doubtful fracture near joints ; but in the deeper
aoft tiflsnes less blood is shed ; and, commonly, in the periosteum, near
the broken ends of the bone, only a few spots of blood are seen. I have
already spoken (p. 128) of the manner in which the extravasated blood is
dispoeed of; and since it rarely appears to take part in the reparative
pioeess^ I shall make no further mention of it.
Borne days elapse, after a fracture, before any clear marks of a repa-
latiTe process can be found. An early consequence of the injury appears
to be the exudation of a small quantity of inflammatory lymph ; so that
tbe oellolar tissue in and near the seat of injury appears more succulent
than is natural, being infiltrated with a serous-looking fluid, in which are
eelb like those of granulations or lymph.
Ill bad cases, this exudation may increase, and add to the swelling
that is often seen to augment in the second or some later day ; but, in
11
162 REPAIR OF FRACTURES.
better instances of repair, and when the parts, even though much injured,
are kept at rest, I think the inflammatory exudation usually ceases after
the second or third day, and that, then, some days pass before the pro-
per reparative material is produced.* The state of the injured parts
during this period of calm, or of incubation, is probably like that observed
in wounds of soft parts (page 138). Its duration is uncertain^ bnl I
think, in the adult, is rarely less than one week or more than two.
In this long period of inaction we find the first contrast between the
repairs of fractures in man, and in the animals that have been used for
experimental inquiry into the process, as dogs, rabbits, pigeons, and
others. In any of these, an abundant reparative material will be pro-
duced, and organized into cartilage or bone, in a time little longer than
elapses before the first commencement of the process in a man.t We
cannot, therefore, from the rapidity of repair in any lower animals, form
any just calculation of its rate of progress in ourselves.
The proper reparative process, commencing after this period of rest,
may usually be divided into two chief parts; namely, the process of'
uniting the fragments, and that of shaping or modelling them and fhoir
combining substance. The uniting and the modelling parts of the pro-
cess are so different in nature and in time, that they may well be omi-
sidered separately. They are comparable with the forming and the
subsequent perfecting of the scars of wounded soft parts ; and in the
union of fractures, even more evidently than in any other instance of
repair, we may note how safety is first provided for, then symmetry; how
the welfare of the individual is first secured, and then the conformity of
the repaired part to the typical or specific form : for the modelling
scarcely begins before the uniting is completed.
The union of fractures is commonly effected by the organization of
new material connecting the fragments. Sometimes, indeed, immediate
union occurs. When portions of bone are placed and held in exact ap-
position, they may be united without any new material being formed for
their connexion ; a continuity of tissues and of bloodvessels being re-
stored, as in the cases of healing by immediate union of soft parts. But
this is rare, and has not yet been sufiiciently studied.
The material deposited for the more usual method of repair of simple
fractures, — the callus, as it is called, when it has become firm or hard,—
is, I think, in the first instance, not visibly different from the material
formed for the repair of other subcutaneous injuries. Its peculiarity is
shown in the direction and end of its development ; and, in this respect,
the repair of fractures supplies an extreme case of the variety of ways
through which the same end of development may be attained.
• More concerning this inflammatory exudation will be related in the account of the repair
of tendons in the next lecture.
t See Nos. 418, 419, 420, in the Museum of the College ; and Series iii^ Noa. 69, 70, 71,
&c., in that of St. Bartholomew's.
BIPAIE OV FRA0TUBE8. 168
In its first production, the reparative material is a structureless, or
diml j-shaded, or granular substance, like fibrine ; or, perhaps at a later
period, it is ruddy, elastic, moderately firm and succulent, like firm gra-
ntdataon-eabstance. Of the manner in which it is placed, in the space
and in the tissues around or between the fragments to be connected, I
win speak presently. At first, it has none of the firmness belonging to
the ^ callus :" this, however, it soon attains, as it makes progress towards
being transformed into bone. Its ossification, as I kave said, may be
aecompliahed through several transitional forms of tissue, which might
be distingoished as so many varieties of callus, if the term be worth
retaining. It may become, before ossifying, either fibrous or cartila-
ginous, or may assume a structure intermediate between these ; and, in
dther of these cases, ossification may ensue when the previous tissue is
jet in a rudimental state, or may be delayed till the complete fibrous or
cartilaginous structure is first adiieved.
I cannot tell the conditions which will determine, in each case, the
iwie of development towards bone that the reparative material will take ;
■or in what measure the difierences that may be observed are to be
aseribed to the seat or nature of the injury, or to the condition of the
patient. All these things have yet to be determined; and I believe that
years at patient and well-directed investigation will be requisite for
them. I can do little more than point out the modes in which the ossi-
fication may be accomplished.
And, first, it may be accomplished throu^ perfect fibrous tissue.
Thus I found it in a case of fracture of the lower part of the femur after
six weeks, and in a fracture of the radius after about nine weeks ; thus,
too^ I think, whatever new bone is formed after fractures of the skull is
derdoped ; and thus one may find, in the neighborhood of fractures and
other injuries of bone, ossifications of interosseous fibrous membranes,
and of the tissue of the periosteum, or just external to it.*
Bat, secondly, the new bone may be formed by ossification of the
fibrous tissue in a rudimental state. And this rudimental state may be
that either of nucleated cells or nucleated blastema. Through nucleated
cells, as the embryo-forms of fibrous tissue, bone is formed when granu-
lations or inflammatory exudations ossify. The process may be often seen
in the union of compound fractures, or of simple ones when much inflam-
mation has been excited. But, best of all, though here only for illus-
tration of what may occur in fractures, the ossification of nucleated cells,
in granulations may be observed, when bone is formed in the mushroom-
shaped mass of granulations that is protruded through the medullary
cai^ of a bone sawn across in an amputation.f In s.11 these cases there
* The thin plate of bone which closes in the exposed medullary canal of the end of a
fractnred long bone, where one ihigment overlaps another, will osuallyt I think, present a
good example of ossification of fibrous tissue.
t College Museum, Nos. 552, 553.
164 BIPAIB OF FBA0TUB18.
appears to be a direct transformation into bone, without the intenrentiQii
of either cartilage or perfect fibrous tissue.
The ossification of nucleated blastema, such as I have described as t
rudimental form of fibrous tissue, may also be seen in simple firactures;
and my impression is, that it is an ordinary mode of ossification in smple
fractures of adult long bones that unite well and quickly. In such a
case, in a fracture of the tibia of five weeks' date, I found, in long-coih
tinned examinations, that the bone is formed without any intermediate
state of cartilage; a finely and very closely granular osseous depoofc
taking place in the blastema, and gradually accumulating so as to form
the delicate yet dense lamellae of fine cancellous tissue. The nuclei of
the blastema appeared to be enclosed in the new-forming bone, and I
thought I could trace that they became the bone-corpuscles ; but I oooU
not be sure of this.
Thus, the new material produced for the repair of fractures may be
ossified through an intermediate fibrous stage. In other instances it B^t .
pass through a cartilaginous stage. In animals, perfect cartilagOi lH|p
its characteristic homogeneous intercellular substance, its cells, aad'^lK*
the characters of pure foetal cartilage, may be produced. Through At
ossification of such cartilage, Miescher"*" and yoetch,t and others, de-
scribe the repair of fractures as accomplished in dogs, pigeons, and other
animals. I have not yet found the very same process in the human sub-
ject ; but I should think it would occur in favorable instances of simple
fracture in children. In youths and adults, I have found only varieties
of fibrous cartilage ; and these have presented numerous gradations from
the fibrous towards the perfect cartilaginous structure. In difiisrent spe-
cimens, or sometimes even in different parts of the same, the reparative
material has displayed, in one, fibrous tissue with a few imbedded oor-
puscles like the large nearly round nuclei of cartilage cells ; in another,
a less appearance of fibrous structure, with more abundant nucleated
cells, having all the characters of true cartilage-cells ; and in a third, a
yet more nearly perfect cartilage.^
Through any of these structures the reparative new bone may be
formed. It may be formed, first, where the reparative material is in
contact with the old bone, and thence extending, it may seem as if it
grew from the old bone ; or it may be formed in the new material, in
detached centres of ossification, from which it may extend through the
* De Inflammatione Ossium, 1836.
t Die Heilung der KnochenbrOche, 1847.
]: I do not describe the minute methods of ossification occurring in the caUoi, or repart"
tive material ; for my opportunities of studying it in man have been too few for me to coii'
elude from : and, although I have seen nothing opposed to the belief that the normal methods
of ossification are imitated, yet the process seems capable of so many modifications that I
think it would not be safe to adapt, unconditionally, to the case of the reparative material
in man, such conclusions as are drawn from the normal ossification of his skeletoo, or from
the ossification of the reparative material in lower animals.
BBPAIB OF FRACTURES. 165
mtenrening tissues, and connect itself with the old bone. (See figs. 21
and 23.)
The new bone, through whatever mode it is formed, appears to acquire
quickly its proper microscopic characters. Its corpuscles or lacunas,
being first of simple round or oval shape, and then becoming jagged at
dieir edges, subsequently acquire their canals, which appear to be gra-
dually hollowed out in the preformed bone, as minute channels commu-
nicating with one or more of the lacunse. The laminated canals for
Uoodyessels are later formed. At first, all the new bone forms a
ninotely cancellous structure, which is light, spongy, soft, and succulent,
with a reddish juice rather than marrow, and is altogether like foetal
bones in their &rst construction. But this gradually assimilates itself to
the structure of the bones that it repairs ; its outer portions assuming a
compact laminated structure, and its inner or central portions acquiring
wider cancellous spaces, and a more perfect medulla. It acquires, also,
a defined periosteum, at first firm, thin, and distinctly lamellar, and gra-
»>4biUy assuming toughness and compactness. But, in regard to many of
> Aese latter changes in the bonds of union of fractures, there are so many
WnBtieB in adaptation to the peculiarities of the cases, that no general
aoooont of them can be rendered.
A subject of chief interest in the repair of fractures is the position of
the reparative material, and in relation to this we find a greater dif-
ference than any yet mentioned between the processes traced respectively
in man and in tiie animals submitted to experiments.
There are two principal methods according to which the reparative
material or callus may be placed. In one, the broken ends or smaller
fragments of the bone are completely enclosed in the new material ; they
are ensheathed and held together by it, as two portions of a rod might
be by a ferrule or ring equally fastened around them both. In such a
case, illustrated by fig. 21, the new material, surroimding the fracture,
has been usually called ^^provisional callus," or ^^ external callus:'' but
the term ^^ensheathing callus" will, I think, be more explanatory. In
the other method (as in figs. 22 and 23), the new material is placed only
between those parts of the broken bone whose surfaces arc opposed ; be-
tween these it is inlaid, filling the space that else would exist between
them, or the angle at which one fragment overhangs another, and uniting
them by being fixed to both. Reparative material thus placed may be
called "intermediate callus." In either method (as in figs. 21 and 22),
there is usually some reparative material deposited in and near the broken
medullary tissue ; and this may be still named " interior callus."
The method of repair with an ensheathing or provisional callus is rarely
observed in man, but appears to be frequent in fractures of the long bones
in animals.^ From these it has been admirably described by Dupuytren
• Even in animals it is not constant To obtain what would be called good specimens of
proTisiaDal callus, the injuries must be inflicted upon young animals, and among these I
166 KBFAIB OV FBACTUBEB.
and others. The chief featnres of the process are as follows (omitting
dates, which have not been ascertuned in man, and cannot well be cal-
culated for him) : —
In the simplest case, when the fragments (represented in thii
dog's tibia ; fig. 21) lie nearly in appoaition, and nearly correspond,
__ „ the reparative material accumulate!
at once around and within them, and
in any interspaces that may be left
between them, that is, the unsheathing
callus, forms most quickly and in
greater abundance, and lies chiefly m
solely between the wall of the bone
and the periosteum, which is thns
lifted np from the wall, the blood-
vessels that passed from it into the
bone now passing to their destinadoBt
through the callus. The distance froH*-,
the broken ends to which the oallM
extends up each fragment is anea^
tain : in the long bones of dogs, and
the ribs of men, it is osnally about
half an inch. The thickness of the
callus is greatest at a little distance
irom the plane of the fracture : ex-
actly in that place, it is nsoally less
thick than either above and below;
so that, even when it is osaified, it is
often marked with a slight winnlar
constriction.
The interior callus fills up the spaoei
in the cancellous tissue, extending in
the medullary canal of each fragment to
a distance somewhat short of that to which the ensheathing callus reaches.
At the end of each fragment there is usually an abrupt contrast between
the firm reparative material that forms this interior callus, and a softer
substance, like that of granulations, which remains between the fing-
meats even till the callus without and within is quite ossified. As the
section drawn in fig. 21 shows, the reparative material is abundant and
cannot but auspecl that particular initancei liave been selected Ibr description; tlioie in
which less callus was formed having been put aside as imperl^t instances of rep»ir, tboogti.
in InitU, they may have lUspIeyed the more natural process. Such good apeoiment are in
the Museum of the College, Nos. 418 la4SG; and in that of St Banholamew'i, Sei. iiU 09,
7(1, 71, ei, 82, 92, W, lOQ, Fig. SI is drawn Tiom No. 06. Il is very desirable (o obtaiD
examinattons of fractured long bones recently united in young children ; foi il is probable
thai in lhe>e ibe process would be very like that described f^om the eipeiiineDti oo uiinial*
No opportunity for such an eiaininntioa ba« yel occurred to me.
BBPAIB OF FRACTURES. 167
well developed both around and within the fragments : but between them,
u e.j in the plane of the fracture, it is sparingly formed and soft, so that
the firagments, if the ensheathing callus were removed, would be no longer
held together ; they are, in fact, combined long before they are united.
The oeaification of the ensheathing callus is accomplished chiefly or
solely by outgrowth of bone from the fragments on which it is placed.
Here, idso, the same method of progress is observed, in that the forma-
tion of new bone extends gradually towards that part of the callus
which exactly corresponds with the plane of the fracture. This part of
the callus is last ossified ; but, at length, its ossification being complete,
the firagments are combined by and within a sheath or ferrule of new
bone. The interior callus, ossifying at about the same time, consoUdates
the cancellous tissue of the fragments, and, at a later period, unites
them. The walls remain still longer disunited. The ossified callus is,
indeed, sufficient to render the bone fit for its office, but it retains the
nearly cancellous tissue of new bone, and it is still only provisional : for
when the walls of the fragments are themselves united, and their con-
tmoitj is restored, all, or a part, of the external callus is removed, and
the cancellous tissue loses its solidity by the removal of the internal
Gillug.
Such is the process of repair with an ensheathing callus. It is, as I
have said, usual in animals ; but in man I have never seen its occurrence
as a natural process in any bones but the ribs. In these it may be traced
as perfectly as I have described it from the instances of repaired fractures
of long bones in the rabbit and dog. Sometimes, indeed, a similar
procees occurs in other human bones : I have seen it in the clavicle and
humerus;* but in both these cases the more proper mode of repair
had been disturbed by constant movement of the parts, and in the
humeros the process had manifest signs of exaggeration and disease.
The normal mode of repair in the fractures of human bones is that
which is accomplished by '^ intermediate callus." The principal fea-
toree of difference between it and that just described are, (1) that the
reparative material or callus is placed chicfiy or only between the frag-
ments, not around them ; (2) that, when ossified, it is not a provisional,
but a permanent bond of union for them ; (3) that the part of it which
is external to the wall of the bone is not exclusively, or even as if with
preference, placed between the bone and periosteum, but, rather, in the
tissue of the periosteum, or indifferently either in it, beneath it, or
external to it.
When the fragments are placed in close apposition and correspondence,
they may, I believe, be joined by immediate union ; but if this do not
* Muwiim of Sl Bartholomew's, Ser. iii. 02, 65, and 66. The clavicle was broken twelve
weeks before death; but the fracture was not detected, and the fragments were allowed to
move onrestmined. The humerus was taken from a man who died some weeks af\er the
fiactnre, and whose arm had, for several days af^er the injury, been the seat of severe
spasms. See Mr. Stanley*s " Illastratkms of Diseases of Bones,*' PI. xxiiL fig. 3.
BBPAIB or FBACTUBB8.
happen, a thin layer of reparative material ia deposited between then ;
it does not, in any direction, exceed the extent of the fracture ; neither
does it, in more than a trivial degree, occupy the medullary canal ; hut,
being inlfud between the fragments, and there ossifying, it rMtom
their continuity. The process may be compared with that of union by
primary adhesion.
When, as more commonly happens, the fragments, though closelj
apposed, do not exactly correspond, but, at certain parts, project mors
or less one beyond the other, the reparative material ia, as in the former
case, inlaid between them, and, to a slight extent, in the medullary caoil:
but it is, also, in larger quantity, placed in the angles at which the frag-
ments overhang one another. Its position is, in these cases, well sbownin
the specimens drawn in the 22d and 23d figures. In the fractured radial*
(Gg. 22) the carpal portion, laterally displaced, projects beyond the
rig.ss. re
radial margin of the upper and impacted portion ; and the angle between
them ia exactly filled, without being surpassed, by a wedge-shaped mass
of reparative material. So, but less perfectly, is the angle on the other
side. In the fractured femurf (fig. 23), with great displacement of the
BIPAIB OF FBAOTUBBS. 169
firagments, the same role is obserred ; the interspace between the frag-
ments, and parts of the angles at which the one projects beyond the other,
are filled with partially ossified reparative material. In neither case is
there an ^isheathing callus ; in neither is any reparative material placed
on that aspect of the one fragment which is turned from the other.
Lastly, when the fragments neither correspond nor are apposed, when
one completely projects beyond or overlaps another, and when, it may be,
a wide interval exists between them, still the reparative material is only
placed between them. It just fills the interval ; it does not even cover
the ends of the fragments, or fill any part of the medullary canal : much
less does it enclose both ends of the mutually averted surfaces, as the
proviflional callus would in a similar fracture in a dog or a rabbit ; it
passes, bridge-like, from one fragment to the other, and thus, when ossi-
fied, combines them. Thus it appears in the fractured femur, part of
which 18 represented in fig. 24.*
The three instances which I have cited, of different relative positions
of the fragments, may suffice as examples of classes in which nearly all
simple fractures of long bones might be described. But, whether the
displacement were like either of these, or of any other kind, I have seen
no examples (other than the exceptions already mentioned) in which the
reparative material has been placed according to a different method.t It
is always an intermediate bond of union ; it is inlaid between the frag-
ments ; and when formed in largest quantity, is only enough to smooth
the chief irregularities, and to fill up the interspaces and angles between
them. And, regarding the particular position which it may in each case
occupy, I do not know that it can be more exactly described, than by
saying, that it is deposited where it is most wanted for the strengthening
of the bone ; so that, wherever would be the weak part, if unhealed,
there is the new material placed, in quantity as well as in position just
adapted to the exigencies of the case, and restoring, as much as may be,
the original condition and capacities of the bone.
If, now, it be inquired why this difference should exist in the corre-
sponding processes in man and other animals, I believe it must be ascribed
principaUy to two causes, namely, the quietude in which fractures in our
* Mtueum of St Bartholomew's Hospital, Set. iii. No. 98.
1 1 exhibited at this lecture all the specimens of fractures examined within six months of
the injury that are contained in the Museums of the College and St Bartholomew's ; and they
all, with the exceptions already mentioned, exemplified this account of the repair by inter-
mediate callos, and of the absence of provisional or ensheathing callus. They included a
radius, four weeks af\er the fracture; another, four or five weeks; a tibia, five weeks; a
femur, six weeks ; another of the same date ; a third, about eight or nine weeks ; a radius,
of somewhat later date; a tibia, eight weeks; a fibula, eleven weeks; a tibia, twelve weeks;
a tibia, sixteen weeks after the -injury; and many others of various but unknown dates, all
in process of apparently natural repair. Since the lecture was given, the description has
been confirmed by many examinations J^y myself and others. It is similarly approved by
specimens in which the union has been long completed ; but less satisfactorily, because it
might be said that we cannot tell how much callus may have been removed.
170 REPAIR OF FBAOTUBBS.
bones are maintained, and the naturally greater tendency to the produc-
tion of new bone which animals always manifest. Even independently
of sorgery, in the case of fractures of the lower extremity, the hmnan
mode of progression almost compels a patient to take rest : and in firao-
tures of the upper extremity, the circumstances of human life and sodetj
permit him to do so far more than other animals can. The whole process
is, therefore, more quietly conducted ; and, as we may say, there is com-
paratively little need of the strength which the formation of provisional
callus would give a broken limb.
The exceptions to the rule, of difference in the repair of human bones
and those of animals, confirm it as thus explained ; for they are found in
the ribs, which are certainly never kept at rest during all the time neces-
sary for repair after fracture, and in bones of which, from various causes,
the repose of the fragments has been disturbed, or which have been the
seats of disease, with inflammatory deposit, during or subsequent to the
reparative process.
The comparative restlessness of animals is, however, I think, not alone
sufficient to account for all the difference in the processes. The remain-
der maybe ascribed to their greater tendency, in all circumstances, to the
formation of new bone. Not in fractures alone, but in necrosis this is
shown. It is very rarely that such quantities of new bone are formed in
even children, as are commonly produced after necrosis of the shafts of
bones in dogs or other animals ; nor is there in the human subject any such
filling up of the cavities from which superficial sequestra have been sepa-
rated, as the experiments of Mr. Hunter showed, after such exfoliations
from the metatarsal bones of asses.*
It remains, now, that I should describe the later part of the repair of
fractures — that which consists in the shaping or modelling of the frag-
ments and of their bond of union.
Omitting the removal of the provisional callus, where such an one has
been formed, this modelling is best observed when there has been much
displacement of the fragments. In these cases, the chief things to be
accomplished are, 1st, the removal of sharp projecting points and edges
from the fragments ; 2dly, the closing or covering of the exposed ends of
the medullary tissue ; 3dly, the forming a compact external wall, and
cancellous interior, for the reparative new bone ; and lastly, the making
these continuous with the walls and cancellous tissue of the fragments.
The first of these is effected by the absorption of the offending points
and angles; and an observation sent to me by Mr. Delagarde tells much
* Museum of the College, Nos. 641 to 653.
The denial of tlie formation of an ensheathing callus in the repair of fractures is some-
times met by the statement that such a callus can be often felt during life. The deception
is produced either by thickening and induration of the soA parts around the fhicture ; or by
the two overlapping ends of the fragments being grasped at once ; or, much more rarely, by
new bone accumulated about the fragments in consequence of inflammation.
BCPAIK OF FRACTDBBS.
171
of the prooen: "A patient in the Exeter Hospital had a bad commi-
nnted fracture of the leg, and a long spike of the tibia, including part
of its apine, conid aot be reduced to its exact level, bnt continoed sensibly
derated, though in its dne direction. At the end of five veeks (onion
having taken plaoe) the end of the spike began to soften ; at six, it was
quite soft and flexible ; at the conclnsion of the seventh week it was
Umtt and shmnken. Six months later, the cartilaginoiu tip had disap-
peared, and the spike was rounded off."
I have since, in a similar case, seen iif.u-
the same process repeated. Both
eases seem to show that the absorption
of the bone is accomplished, as Mr.
Hunter described it in cases of necrbeis,
1^ removing first the earthy^ matter,
aiid thea the softened remains of ani-
mal substance.
The closing or covering-in of the
parte of the broken medullary tube,
wUch are exposed in fractures with
much displacement, is slowly accom-
plished by the formation of a thin layer
of eompaot bone, like that which covers
the cancellous tissue at the articular
ends of bones. It is well shown in the
original of the 24th figure.* In a
fracture of the femur, after six weeks,
I have seen the exposed medullary tube
oovered-in with a thin fibrous mem-
brane, tense like a drum-head, new-
formed, and continuous with the perios-
teum. The permanent closure appears
to be effected by the ossification of such
a membrane; and the new bone be-
eomee smoothly continuous with the
Tonnded and thinned broken marine
ef the walls of the old bone. So are
^ enib of stamps covered-in; and
ndtherin these nor in fractures have I seen new bone extending into the
mednlluy canal, as if fomrtd by the ossification of an internal callus.
The same sketch shows the nearly completed formation of distinct
walls and medullary tissue in the bridge of new bone connecting the
two fragments of the femur. At an earlier period we may be sure that
aQ this new bone was soft and cancellous ; it has now acquired the tex-
* Fiom ihe Huanim of Sl fiaittioloniew'*, Ser. iU. No. 68.
172 BSPAIB OF FBACTUBBS.
tares proper to the bone which it repairs, and, as if to complete its con-
formity with the structures among which it was thus, by accident, intro-
duced, the process was begun by which the new and the old compact
and medullary tissues would become respectively continuous. Already
those parts of the walls of the shaft that intenrene like partitions, sepa-
rating the new from the old medullary tissue, are thin, uneven on their
surfaces, and in their interior half-cancellous. At some later time they
would, probably, have been reduced to mere cancellous tissue, and ti»o
repair of the fracture would have been completed, crookedly indeed, but
with unbroken continuity of tissue.
To adapt the foregoing account to the case of compound fractures, it
is, I believe, only necessary (so far at least as the normal process of
repair is concerned) to say that the reparative material is more mingled
with products of inflammation ; that that part of it which is formed
within reach of the air, or in a suppurating cavity, is developed to bone
through the medium of granulations, like those formed in open wounds
of soft parts ; and that the whole process of repair is, generally, slower,
less secure, and more disturbed by morbid growths of bone, and other
effects of what has been named '^ ossific inflammation."
The data, at present collected, concerning the times in which the
several parts of the reparative process are usually completed after frao-
tures of adult human bones, are not sufficient for more than a general
and approximate estimate. They may be thus generally reckoned. To
the second or third day after the injury, inflammatory exudation in and
about the parts ; thence to the eighth or tenth, seeming inaction, with
subsidence of inflammation ; theuce to about the twentieth, production of
the reparative material, and its gradual development to its fibrous or
cartilaginous condition ; thenceforward its gradual ossification, a part of
the process which is, however, most variable in both its time of com-
mencement and its rate of progress, and which is, probably, rarely com-
pleted before the ninth or tenth week, although the limb may have long
previously recovered its fitness for, support or other use. From this
time the rate of change ia so uncertain, that it is impossible to assign the
average time within which the perfection of the repair is, if ever, accom-
plished.
The consequences of failure in the process of repair may be illustrated
by what I have described as its normal course. In a large part of the
cases of ununited fracture the fragments are connected by fibrous or
fibro-cartilaginous tissue, inlaid between them. Such is the defective
imion of most cases of fracture of the neck of the femur within the
capsule, and of the olecranon and the patella when their fragments are
not held close; and such a defect may occiur in any long bone. It is an
BIPAIB OF FBAOTUBES. 178
example of arrested development of the reparative material ; and may be,
in this respect, compared with the condition of granulations whose cells
persist in their mdimental form. Every other part of the process may
be complete ; but this part fails, and the fragments are combined by a
yielding, pliant, and almost nseless bond.
In other cases, the failure seems to occur earlier. No reparative
material is formed, and the firagments remain quite disunited. This
may be the result of accidental hindrances of the normal reparative
process: but it sometimes appears like a simple defect of formative
power ; a defect which, I believe, cannot be explained, and which seems
the more remarkable when we observe the many changes which may, at
a later time, be effected, as if to diminish the evil of the want of union.
•Thus, commonly, the ends of bones thus disunited become covered with
a thin layer of fibrous tissue, polished as if with a covering of epithelium,
and as smooth as an articular surface : similar smooth linings form in the
cavities that enclose them ; the tissues immediately around them become
condensed and fibrous ; and thus, at length, the ends of the fragments
are brought to the imitation of a joint, in which they may move without
mutual injury. Or else, in the place of such a false joint, the end o^
each fragment has a kind of bursal sac formed on it, protecting the
adjacent parts from injury in its movements. But, much as may be
thus accomplished, new bone is not spontaneously produced. As the
result of disease, it may be formed ; and in this case it is often formed
uselessly, and without evident design, in heaps or nodules about the ends
of the fragments ; yet it is of such disease that surgery may often make
happy use when it can excite inflammation of the fragments, and so
hold them close that the new bone may grow between or around them,
and fasten itself to both."*"
* It wiU diminiflh the defects of the foregoing description of the repair of fractures, which
I have drawn almost entirely from my own observations, if I subjoin a list of the works
especially or chiefly devoted to this subject, in which the reader may find the best help to
m larger knowledge of the snlgect
Dnpaytren : Expose de la Doctrine de M. Dupuytren sur le Cal, par Sanson. In Journ.
TTniv. des Sciences M^dicales, t zx.
Breschet : Recherches ... sur la Formation du Cal ; Thdse. Paris, 1819.
Howahip: On the Union of Fractured Bones. Med.-Chir. Trans, vol. ix.
Hiescher: De Inflammatione Ossium eorumque Anatome. Berlin, 1836.
Fkmrens: Sur le D^veloppement des Os et des Dents. Paris, 1842.
Lebert: Sur la Formation du CaL In his Physiologic Pathologique, t iL Paris, 1845.
Voetich : Die Heilnng der KnochenbrOcke. Heidelberg, 1847.
Stanley : Illustrations of the Effects of Disease and Injury of the Bones, p. 27. 1849.
Malgaigne : Trait6 des Fractures et des Luxations, t i. Paris, 1847.
Dusseau : Onderzoek van het Beenweefsel en Verbeeningen in zachte Deelen. Amster-
dam, 1850.
174 HSALIKG OF OABTILAGl.
LECTURE XIL
HEALINa OF INJURIES IN VARIOUS TISSUES.
This last lecture on the process of repair I propose to devote to the
consideration of the modes of healing of several different tissues ; modes
which, although they be all consistent with what has been said of the
general rules and methods of the healing process, yet present each some
peculiarity that seems worthy of observation.
And first (though it matters little which I begin with), of the healing
of wounds and other injuries of cartilage.
There are, I believe, no instances in which a lost portion of cartOage
has been restored, or a wounded portion repaired, with new and well-
formed permanent cartilage, in the human subject. When a fracture
extends into a joint, one may observe that the articular cartilage remains
for a long time unchanged, or else has its broken edges a little softened
and rounded off. In one case, I saw no other change than this in six
weeks ; but at a later period the gap is filled with a tough fibrous tissuey
or, rather, the gap becomes somewhat wider and shallower, and the space
thus formed is so filled up.
The excellent researches of Dr. Redfem'*' have ascertained the method
of this process in incised wounds of the articular cartilages of dogs. As
showing the slowness of the repair, he found in one instance, in which he
made three incisions into the cartilage of a patella, and two into that of
the trochlear surface of the femur, that no union had taken place in
twenty-nine weeks. No unusual cause for the want of union had been
apparent, yet a reparative process had but just commenced. In another
case, twenty-five weeks and four days after similar incisions, he found
them completely and firmly united by fibrous tissue formed out of the
substance of the adjacent healthy cartilage. The cut surfaces of the
cartilage were very uneven, and were hollowed into small pits, produced
by the half-destroyed cartilage-cells, the former contents of which were
now lying on the surface. No evident change had taken place in the
texture of the cartilage at a little distance from the cut surfaces, except
that here and there the intercellular substance presented a fibrous appear-
ance. The substance uniting the cut surfaces consisted of a hyaline,
granular, and indistinctly striated mass, in which were numbers of rounded
oblong, elongating, or irregularly-shaped corpuscles. A nucleated fibrous
membrane, formed by the conversion of the superficial layers of the car-
tilage bordering the wounds, was continuous with their uniting medium.
" The essential parts of the process [of union of such incised wounds]
* Anonnal Nutrition in Articular Cartilages: Edinburgh, 1850. And, On the Healing
of Wounds in Articular Cartilages: in the Monthly Journal of Medical Science, Sept., 1851.
HlALUfG OF TSKDOlfS. 175
appear to be," Dr. Bedfem concludes, ^^ the softening of the interceUular
substance of the cartilage, the release of the nuclei of its cells, the for-
mation of white fibrous tissue from the softened intercellular substahee,
and of nuclear fibres by the elongation of the free nuclei."
Such a process has peculiar interest as occurring in a tissue which has
^0 bloodvessels, and in which, therefore, the reparative material is fur-
nished by transformation of its own substance, not by exudation from
the blood. In the same view tlje results of inflammation of articular
cartilage will have to be particularly noticed.
In membraniform cartilages that have perichondrium, the healing pro-
cess isy probably, in some measure, modified; a reparative material
being furnished, at least in part, from the perichondria! vessels. The
cartilaginous tissue was less changed than in Dr. Bedfern's cases, in an
example of wounded thyroid cartilage that I examined. A man, long
before death, cut his throat, and the wound passed about half an inch
into the angle of his thyroid cartilage. In the very narrow gap thus
made, a gap not more than half a line in width, there was only a layer
of tough fibrous tissue ; and with the microscope I could detect no appear-
ance of a renewed growth of cartilage. The edges of the cartilage, to
which the fibrous tissue was attached, were as abrupt, as clean, and as
straight, as those would be of a section of cartilage just made with a very
sharp instrument. The cut cartilage was unchanged, though the union
between it and the new-formed fibrous tissue was as close and as firm as
that of the several parts of a continuous tissue. The perichondrium
on both sides was equally firmly attached to the fibrous bond.
In some instances (but I suppose in none but those of cartilages which
have a natural tendency to be ossified in advancing years) the fractures
of cartilage may be united by bone. This commonly happens in the
costal cartilages; and it has been noticed in fractures of the thyroid
cartilage. The union of a fracture of the cartilaginous portion of a rib
is usually effected, as that of one in the osseous portion is, by an enclosing
ring of bone, like a provisional external callus ; and the ossification ex-
tends to the parts of the cartilage immediately adjacent to the fracture."*"
HsAUNG OP Tendons. — ^I have abready often referred to the pheno-
mena that follow the division of tendons by subc^aneous and by open
wounds ; but the practical interest of the subject will justify my giving a
connected account of the process, as I observed it in a series of numerous
experiments performed, with the help of Mr. Savory, on rabbits from
three to six months old. Such experiments are, I know, open, in some
measure, to the same objection as I showed in the last lecture to those
on fractures in the lower animals ; but the few instances in which exami-
* Miuetiin of the College, No. 377 ; and of St Bartholomew's, Ser. in., No9. 48, 73.
Nmnerons examples of the partial repair of larger injuries of articular and other cartilages
will be foand in Hildebrandt's Anatomie, B. i. p. 306.
This hook iii i/rO ju
176
HBALtVa or TBHDOKB.
BftUons have been made of human tendona, divided by anboataneon
BectioD, bare abowD tbat the procesaes is man and in animals are not
materially different. The chief differences are, we may believe, that, ai
in the repair of bones, the production of reparative material is more
abundant, and its organization more speedy, in animalii than in man.
I have already, in the second lecture, stated generally the difference!
in the several consequences of open and Bubcutaneoua wounds. In the
case of divided Achilles tendons, the disadvantagee of open wounds, i. &
of wounds extending through the integuments over and on each mde of
the tendon, ae well as through it, were as followa: — 1. There were
always more inflammation in the neighborhood of the wound, and more
copious infiltration of the parts, than in a aubcutaneons division of ths
tendon in the same rabbit ; 2. Suppuration frequently occurred, rither
between the retracted ends of the divided tendon, or beneath its distil
end ; 3. The skin was more apt to become adherent to the tendon, and
so to limit and hinder its sliding movements, when the healing was oom-
pleted ; 4. The retracted ends of the tendon were more often displaced,
BO that their axes did not exactly correspond with each other, or with
that of the reparative bond of union. Such mishaps were often obaerrtd
in the open wounds, but were rare afW the subcutaneous operations. In
the cases of open wonuda, they were avoided aa often as the wound
through the integuments healed quickly ; and, whenever this happened,
the case proceeded like one in which the subcutaneous division had been
made. It was evident that the exposure of the wounded parts to the air
did little harm, if it was continued for only a few hours ; a fact that may
be uaefuUy remembered when operations moat be performed on tendons
which it is not convenient to divide nnseen.
HEALIKQ OF TENDONS. 177
These same cases of speedy healing of the opening in the integuments
wrved to show, that it is miimportant for the healing of divided
Ichilles tendons, whether the cellular* sheath or covering of the tendon
le divided or not. In all the cases of open division in these experiments,
ft was completely cut through; yet, when the external wound healed
picUy, the union of the divided tendon was as speedy and as complete
IS in any case of subcutaneous division in which it might be supposed
liaft the sheath of the tendon was not injured.
I will describe now the course of evj^nts after subcutaneous division of
he Achilles tendon; stating only what was generally observed, and
Dnstrating it, as far as may be, with the annexed diagram (fig. 25), in
fUch, as in longitudinal sections, A may represent the natural condition
if the tendon and its muscles, and the succeeding figures the effects of
Is division and the successive stages of its repair.*
At the instant of the division, the ends of the tendon separate to the
lisftance of nearly an inch, the upper portion of the tendon being drawn
up the leg by the action of the gastrocnemius and soleus muscles (b).
Die retraction is comparatively much greater than is usual in operations
m the human Achilles tendon ; for where these are done, the muscles
ire seldom capable of strong or extensive contraction. It is in all cases
to be remembered that the separation is effected entirely by the with-
drawal of the upper portion of the tendon ; the lower, being not con-
nected with muscle, remains with its end opposite the wound. To this
ire may ascribe the general fact that the reparative process is more
ictivc, and the inflammatory process less so, at the upper than at the
lower portion of the tendon : for the latter lies in the very centre of the
2hief inflammatory action; while the former is removed far from it, being
Irawn sway, at once from the seat of the injury, and from even the
dightest exposure to the air.
I have already said that very little blood is effused in the subcutaneous
)perations. Commonly, only a few blotches of extravasation appear in
md near the space from which the upper part of the tendon is re-
tracted (b). The first apparent consequence of the division of the
tendon is die effusion of a fluid or semi-fluid substance, which, like the
product of common inflammation, quickly organizes itself into the well-
known forms of lymph- or exudation-cells. These, speedily becoming
more distinctly nucleated and elongated, undergo the changes which I
mentioned in describing the development of cells in granulations. The
exuded lymph makes the tissues at and near the wound succulent and
feDow, like parts infiltrated in anasarca. The bloodvessels near the
* The account here given agrees in all essential respects with that by Lebert, in his
/iUundlungen .... der prakt. Chirurgie, p. 403. Neither do the accounts materially
differ, except in being less minute, which are given by Von Ammon (De Physiologia Teno-
tomiie}, DqtbI (Bull, de I'Acad. Royale de Mddecine, 1837), and Duparc (Nederlandsch
UkDoet, 1837).
12
178 HEALING OF TEKDOKS.
divided tendon enlarge, as in an inflamed part, and appear filled with
blood (b, c). The exudation, together with the enlargement of the ves-
sels, swells the parts, so that the skin is scarcely at all depressed between
the separated ends of the tendon. But in well-made sabcutaneoiiB
sections, this inflammatory product is of small amount, and takes, I
believe, little or no share in the healing of the injury ; for the exudation
ceases after the first twenty-four hours, and I think that its cellB are not
developed beyond the state in which they appear spindle-shaped. I
have never seen indications of their forming filaments of cellular or
fibrous tissue.
In rabbits, forty-eight hours usually elapse before there are distinct
signs of the production of the proper reparative material. This 10
deposited in the fibro-cellular tissue that lies between and close round
the separated ends of the tendon, as well as in the interspaces of the
tendinous fasciculi of those ends. It thus swells up the space between
the separated ends, and makes the ends themselves larger, and somcwhit
ruddy, soft, and succulent. Some portion, at least, of it being deposited
where the inflammatory effusion was, one finds their constituents mingled;
but I believe that, while the proper reparative material developes itself
the product of the inflammation is either arrested in its development^ or
even degenerates ; its cells shrivelling and gradually wasting.
I need not now describe the mode of development of the reparative
material provided for divided tendons : for I have taken it as a typical
example of the development of lymph into nucleated blastema, and tiienoe
into fibrous tissue (p. 129). To the naked eye it appears after three
days as a soft, moist, and grayish substance, with a slight ruddy tinge,
accidentally more or less blotched with blood, extending from one end of
the tendon to the other, having no well-marked boundary, and merging
gradually into the surrounding parts (c). In its gradual progress, the
reparative material becomes commensiurately firmer, tougher, and grayer,
the ruddiness successively disappearing from the circumference to tto
axis : it becomes, also, more defined from the surrounding parts, ancl,
after four or five daysi, forms a distinct cord-like vascular bond of conr
nexion between the ends of the tendon, extending through aU the space
from which they have been retracted, and for a short distance ensheath-
ing them both (d, e).
As the bond of connexion thus acquires toughness and definition, so
the tissue around it loses its infiltrated and vascular appearance : the
bloodvessels regain their normal size, the inflammatory effusion clears up,
and the integuments become looser and slide more easily. In «very ex-
periment, one finds cause for admiration at the manner in which a single
well-designed and cord-like bond of union is thus gradually formed,
where at first there had been a uniform and seemingly purposeless
infiltration of the whole space left by the retraction of the tendon.
With the increase of toughness, the new substance acquires a more
HEALIKQ OF TENDONS. 179
deddedly filamentous appearance and structure. After the fourth day,
Ae microscope detects nuclei in the previously homogeneous fibrine-like
icparatiye material ; and after the seventh or eighth day there appear
idl-marked filaments, like those of the less perfect forms of fibrous
tione. GraduaUy perfecting itself, but with a rate of progress which
beeomes gradually less,"*" the new tissue may become at last, in all
qipearance identical with that of the original tendon. So it has hap-
pened in the valuable specimens presented to the Museum of the College
tjHr. Tamplin.f They are the Achilles tendon and the tendons of the
Ulterior and posterior tibial muscles of a child nine months old, in whom,
when it was five months old, all these tendons were divided for the cure
rf eongenital varus. The child had perfect use of its feet after the
i|ieration, and, when it died, no trace of the division of any of the ten-
koB could be discerned even with microscopic aid.
In the instances of divided human tendons, less retraction, I have
already said, takes place than in those of lower animals. The connect-
9g bond is therefore comparatively shorter ; and it is yet more shortened
flieii, like a scar, it contracts as it becomes firmer. It is impossible,
therefore, to say what length of new material was, in this case, formed
into exact imitation of the old tendon. But, however little it may have
keen, such perfect repair as these specimens show is exceedingly rare.
Ifore commonly the difiierences between the original tendon and the new
nbstance remain well-marked. The latter docs not acquire the uniform
iRsngement of fibres, or the peculiar glistening thence accruing to the
Bonnal tendons: it is harder and less pliant, though not tougher; its
Ebres appear irregularly interwoven and entangled, dull-white, like those
nf a common scar. And these differences, though as time passes they
become gradually less, are always seen when a longitudinal section is
Bttde from behind, through both the ends of the tendon and the new
Bobstance that ensheaths and connects them. In such a section (as in
ig. 25, b), one sees each of the retracted ends of the divided tendon pre-
serving nearly all its peculiar whiteness, only somewhat rounded or mis-
shapen, swollen, and imbedded in the end of the new substance, which is
ihrays grayer, or less glistening, and looks less compact and regular.
In the retracted ends of the tendon, one may discern the new substance
singled with the old and interposed between its fasciculi, with which
one may believe it is connected by the finest dove-tailing.J
The strength, both of the new substance itself, and of its connexion
• One may remark this as a general fact, that when once the reparative process has com-
aeoced, much more appears to* be done in it in the first few days than in any equal sub-
«qiient period of time. It may be another instance justifying the general expression, that
prodocckm is easier than development or improvement, and that the earlier or lower deve-
lopmenti leqnire less organiaeing force than the higher or later.
t Noa. 35S, 359, 360.
X The appearances are shown in specimens in the College Museum, Nos. 348 to 354 ;
md in thoae from the experiments on rabbits in the Museum of St. Bartholomew's.
180 HEALING OF MUSCLES.
by intermingling with the original substance, is worthy of remark. To
test it, I removed from a rabbit an Achilles-tendon, which had been
divided six days previously, and of which the retracted ends were con-
nected by a bond of the size and texture usual at that period of the re-
parative process. I suspended from the half-section of this bond gra-
dually increased weights. At length it bore a weight of ten pounds,
but presently gave way with it : yet we may suppose the whole thickness
of the bond would have borne twenty pounds. In another experiment, I
tried the strength of a bond of connexion which had been ten days form-
ing : this, after bearing suspended weights of twenty, thirty, forty, and
fifty pounds, was torn with fifty-six pounds. But surely the strength it
showed was very wonderful, when we remember that it was not more
than two lines in its chief diameter ; and that it was wholly formed and
organized in ten days, in the leg of a rabbit scarcely more than a pound
in weight. With its tenacity it had acquired much of the inextensibility
of the natural tendon. It was indeed stretched by the heavy weights
suspended from it, yet so slightly that I think no exertion of which the
rabbit was capable would have sufficed to extend it in any appreciable
degree.
The Healing of Muscles, subcutaneously divided, presents many
things exactly similar to those just described as observed in the healing
of tendons similarly divided, and the structure of the connecting repara-
tive bond is of the same kind ; new muscular fibres, I believe, are never
formed. But, in the experiments I made on the triceps extensor brachii,
and the tibialis anticus of rabbits, there arc always observed a peculiar
inversion, subsidence, or tucking-in of the muscular fibres at the divided
part ; so ftiat nearly all the fasciculi directed their cut ends towards the
subjacent bone or fascia. Thus it sometimes appeared to happen that,
though the retracted portions of the muscle were imperfectly united, yet
the action of the muscle was not lost ; for one or both its ends, acquiring
new attachments to the subjacent parts, could still act, though with
diminished range, upon the joint over which its fibres passed.
In general, it appeared that the reparative material was less quickly
produced than after the division of tendons ; but this might be because
of the greater violence inflicted in the operation, more than because of
the structure of the divided parts. The usual method and end of the
development of the reparative material were the same as after division
of the tendons ; and at length, but always, I think, more slowly than
with theifi., the ends of the retracted portions became inclosed in a
tough fibrous bond of union.
After the formation of this bond, the healing of divided muscles
is improved, both by the clearing up of the surrounding tissues infil-
trated with inflammatory products, and by the contraction of the new
bond, which thus draws together the retracted portion of tlie muscle, so
HEALING OF ARTERIES AND VEINS. 181
that they very nearly coalesce. Thus, in a man who had cut his throat
long before his death, and had divided the left stemo-hyoid^omo-hyoid,
and stemo-thyroid muscles, I found that the ends of these muscles,
though they must at first have retracted considerably, had all been
drawn to attachments on the cricoid cartilage, over which their several
portions nearly united.
The Healing of Injured Arteries and Veins is commonly a
more complicated process than those already described, on account of
the changes that ensue in the blood that is stagnant within, or shed
around, the injured vessel.*
Small wounds of either arteries or veins may heal by immediate union,
or primary adhesion, as those of any other tissue may, and the blood shed
into the adjacent tissues may be absorbed as from a common ecchymosis.
An artery di^rided in only part of its circumference, although it may be
for a time contracted, yet does not remain so ; neither is it commonly, in
such a case, obstructed by clot within its canal. Hence, after such
wounds, the pulse in the distal or lower part of the artery is often unaf-
fected. After the first outrush of blood, some that remains extravasated
among the tissues usually clots, and covers the wound in the artery ; but
the closure is often ineffectual, or only for a time, and fresh bleedings
ensue, either increasing the accumulation of extravasated blood, or
poshing out the clots already formed. In this way, with repeated
hemorrhages at uncertain intervals, the wound in an artery is often kept
open, and at the end of two or three weeks may show no trace of
healing, but, rather, appear widened and with softened averted edges.
In such a case, it is possible that the wound in an artery may still heal
by granulations, either rising from its edges or coalescing over it from
adjacent parts ; but the event is too unlikely to justify the waiting for
its occurrence, if there be opportunity for surgical interference.
In the case of an artery divided quite across, three chief things are
to be considered ; namely, the natural immediate arrest of the bleeding,
the closure of the two orifices, and the disposal of the blood that may
become stagnant at and near the ends of the divided vessel.
The bleeding is arrested, mainly by the contraction of the muscular
coat of the artery. Stimulated by the injury and by exposure to the
air, and relieved from much of the pressure of the blood, whose onward
course is less resisted, the muscular tissue of the divided artery contracts
and closes, or, at least, diminishes, the canal. In some instances the
contraction is naiTowly funnel-shaped, and the end of the artery may
be open, while, at a Jittle distance within, its canal is closed or much
• Nearly all that follows relates to tlie healing of wounds of arteries. The process in
veiDB appears to be essentially the same, but more quickly accomplished. See Stilling:
"Die natorUchen Processe bei der Heilung durchschhmgcner Bkitgefasse :" Eisenach, 1834,
p. 147 and 289.
182 HBALING OF ABTEBIBS AND VEINS.
narrower. In some, the exterior layers of the muscular fibres seem to
contract rather more than the interior, and the end of the artery appears
prominent or pouting. Many, perhaps trivial, differences of this kind
may be noticed in different arteries cut across in amputations.
The retraction of the divided artery within its sheath, or among the
adjacent tissues, assists to stay the bleeding, by giving opportunity for
the blood to become diffused, as it flows over the tissues that collapse
over the end of the artery before it closes. But the degree to which
this retraction can take place is very uncertain. It depends chiefly on
the laxity or the closeness of the attachment of the artery to the sur-
rounding tissues, and on the extent to which they with it are divided,
and with it are capable of retraction. In amputations, one sees many
differences in these respects. Arteries divided close to ligamentoos
parts and the origins of the muscles appear much retracted, because the
tissues about them are scarcely at all drawn back ; so it is in amputa-
tions just below the knee : but those that are divided where there is
much cellular tissue, or where muscles are far from their origins, as in
the middle or lower part of the forearm, appear less retracted, becaose
these surrounding parts are retracted as much or more than they. In
like manner, arteries from which branches are given off just above the
place of division retract less than others, the branches holding them in
place.
Equally various is the degree to which the bleeding from a wounded
artery is arrested by the blood collecting around it, and in front of its
orifice. It depends mainly on the degree of retraction of the artery,
and on the facility with which the blood can escape through the extenud
wound. It is assisted, in case of large hemorrhage, by the weakening
of the action of the heart, and, perhaps, by the readier coagulation of
the blood which ensues in syncope.
The efficacy of these means for the arrest of bleeding from all but
the principal arterial trunks, is evident enough immediately after the
amputation of a limb. However many arteries may need ligatures,
they are probably not more than a tenth of those that were just now
traversed by quick streams of blood. The rest are already closed by
their own muscular action, needing no assistance, from a diminished
action of the heart, or the effusion of blood around them.
I know no observations showing the method of healing and permanent
closure -of the small arteries that thus spontaneously cease to bleed.
All the accurate inquiries that I am aware of relate to the closure of
the torn umbilical arteries, which have hardly a parallel in other vessels,
or else to the more complicated cases of large arteries on which ligatures
have been tied, or which have been closed by some artificial means, such
as the "Durchschlingung** of Stilling; a defect much to be regretted,
since the ligature, or any similar means, introduces such a disturbance
into the process of repair, as makes it a morbid process, however advan-
tageous its end may be. Indeed, when a divided artery is tied, the
HBALINO OF ARTERIES AND VEINS. 188
mjor J to be repaired is not that of the wound, but that of the ligature ;
■n injury in which a bruised wound dividing the middle and internal
ooats of the artery, a bruise with continued compression of its external
coat, and the continued presence of a foreign body, are superadded to
the injuries which preceded the application of the ligature.
For simplicity's sake, let us consider the repair of such an injury in
only that part of an artery which is above the ligature, t. e. nearer to
the heart. The changes in the part beyond the ligature are, according
to Stilling, the same, but more quickly accomplished.
Now, in this repair, three parts are chiefly concerned ; namely (1), the
injured walls of the vessel at andr immediately adjoining the ligature ;
(^ the part of the vessel between the ligature and the first branch
iboTB it, through which the blood can flow off; and (3) the blood wMch,
within the same part of the vessel, t. e. between the ligature and the first
branch nearer to the heart, lies nearly stagnant. The healing of the
artery may indeed be accomplished without the help of this blood, but
certain changes in it commonly concur with the rest of the process.
(1.) The injured walls of the vessel, and the tissue immediately around
them, inflame, and exudation of lymph takes place in them, especially
at and just above the divided part of the coats constricted and held in
contact by the ligature. Thus, as by primary adhesion, or by an adhesive
inflammation, the wound made by the ligature in the middle and internal
coats is united ; and, through the same process, this union is strengthened
by the adhesion of these coats to the outer coat, and of the outer coat to
the sheath or other immediately adjacent tissues. There is a general
idheflion of these parts to one another ; they appear thickened, infiltrated,
md morbidly adherent : beneficial as the result is, it is the result of dis-
ease. Through the same disease, the portion of the outer coat of the
irtery included within the ligature nlcerates, permitting the removal of
the ligature, and a more natural process of organization of the inflam-
matory products among which it lay, and which its presence had tended
to increase.
(2.) When any part of an artery, through any cause, ceases to be
traYersed by blood, its walls tend to contract and close its canal. The
ipplication of a ligature brings into this condition all that part of the tied
irtery which lies between it and some branch or branches higher up,
bhrough which the stream of blood may be carried off. The walls of this
Murt therefore slowly contract, gradually reducing the size of its canal,
ind, in some instances probably, closing it. There is not in this, as in
lie last described part of the process, any disease : the contraction is
miy the same as that of the ductus arteriosus, the umbilical arteries, and
rther vessels, from which, in normal life, the streams of blood are diverted ;
knd the closure may, as in thei6, according to Rokitansky,* be assisted
ly deposit from the blood thickening with an opaque white layer the in-
* Patbologische Anatomie, B. ii. p. 623.
184 HEALING OF ABTEBIES AND VEINS.
ternal coat. The time occupied by this contraction, q^d its extent in
length along the artery, are too various to be stated generally. When it
is permanent, the coats of the artery, at its completion, waste, lose their
peculiar structures, and are slowly transformed into fibrous tissue, such as
that which composes the solid cord of the ductus arteriosus.
(3.) Respecting these two consequences of the application of ligatoreBi
little difference of opinion can exist ; and it may be repeated, that either
of these may suflBcc for the safe closure of the artery. Thus, on the one
hand, we sometimes see an artery pervious to the very end of a stumps
but there safely closed at the seat of the ligature ; and, on the other, the
naturally torn umbilical arteries of animals, and, I suspect, the arteries
which in common wounds are divided, and spontaneously cease to bleed,
are closed and obliterated without inflammation. However, much more
commonly, the blood contained in and near the end of the tied artery be-
coming stagnant, concurs with both the processes just described, to the
closure of the canal.
Concerning this third constituent of the process, more questions have
been raised. I shall describe it from the admirable observations of Stil-
ling* and Zwicky.f They were made in large series of experiments on
the arteries of animals : those of Stilling refer chiefly to the changes
visible to the 'naked eye, those of Zwicky to the more minute.
Wlien an artery is tied, the blood, as already said, becomes nearly
stagnant in the canal, from the ligature upwards to the first prindpal
branch. In an uncertain time, varying from one to eighteen hours, a
part of this blood coagulates ; and the clot commonly assumes a more or
less conical form. The base of this " conical clot,** " internal obturator,"
"plug," or "thrombus," rests in and fills the end of the artery, at the
wound made by the ligature ; its apex usually lies nearly opposite the
first branch above, in the axis of the artery : it is surrounded by fluid,
but still nearly stagnant, blood, which, except at its base, intervenes be-
tween it and the internal surface of the artery. At its base, and higher
up if it fills the artery, the clot is dark and soft, like a common blood-
clot : its upper part and apex are denser, harder, and whitish, like coagu-
lated fibrine ; and layers of white substance are often gradually supe^
added to its middle and apex, and increase its adhesion to the walls of
the vessel.
In course of time, the clot becomes marked with paler spots, and then
porous, spongy, and cavernous, as if it were being gradually channelled
from its surface towards its central parts. In this state, injection im-
pelled into the artery will enter and distribute itself in the clot, making
it appear vascular, or like a cavernous tissue. J; While thus changing,
* Die natdrl. Processe bei dor Heilung durchschlungener BIutgeHlsse. Eisenach, 1834.
t Die Metamorphose des Thrombus. Zurich, 1845.
^ It was such an injection probably, that half deceived Hunter into the belief that he had
found the beginning formation of new bloodvessels in the clot (Work^, vol. iii. p. 110; and
HEALING OF ARTERIES AND .VEINS. 186
alBO, it becomes gradually more decolorized, passing through raddy, rosy^
and yellowish tints, till it is nearly colorless. As it loses color, it gains
firmness, and its .base and the greater part of its length become more
firmly adherent to the inner surface of the artery, directly or through
the medimn of the lymph deposited in it. In this increasing firmness,
the clot, moreover, is acquiring a more definitely fibrous texture ; and, as
the same change is gradually ensuing in the inflammatory products de-
posited near the ligature, the clot and they unite more firmly than before.
The walls of the artery, also, gradually closing in on the clot, unite with
it; and, finally, as they also lose their peculiar texture and become
film)iis, the clot and they, together, form the solid fibrous cord by which
the tied portion of the artery is replaced ; a cord which commonly ex-
tends, as did the clot, from the seat of the ligature to the first principal
branch above it.
The minuter changes in the clot, associated with those visible to the
naked eye, are, chiefly, that it acquires a fibrous or fibro-cellular texture,
and becomes vascular. I have already said (p. 120), that Zwicky has
traced the development of the fibrine of the clot into fibrous tissue through
die formation of nucleated blastema ; and, probably, I need not add to
the descriptions of this process already drawn from other though similar
instances of it (pages 128 and 178). The development, or, at least, the
later part of it, is accomplished much more slowly than in the reparative
material of tendons in rabbits ; needing more than ten weeks in the clots
formed in dogs, and more than two years in those in men. The retard-
ation may depend in some measure on the presence of the blood-corpus-
cles in the clot ; for these, though they seem not to affect, or take part
in, the development of the fibrine, yet probably, as they suffer degenera-
tion preparatory to removal, may retard it.*
The bloodvessels usually enter the organizing clot, in dogs, in the
fourth week, when already it has acquired a nucleated and imperfectly
fibrous tissue, and firmness in the place of the spongy texture from which
it had derived a spurious appearance of vascularity. They pass into it,
apparently, from the vessels formed in the lymph exuded within the
artery, in and just above the situation of the ligature ; hence they enter
its lower part, and gradually extend towards its apex.
Such is the important process for the healing of tied arteries. In
applying the description drawn from experiments on animals to the cases
of human arteries, the same allowance must be made as in the repairs of
fractures and of dirided tendons. The process is less speedy, less
simple, less straightforward (if I may so speak), more prone to deviate
•
the Museum of the College, No. 11); and this led Stilling into one of the few errors in his
e»fay, inducing him to believe that the clot thus became vascular independently of the
vessels of the surrounding parts.
• The changes ensuing in the blood-corpuscles are described by Zwicky; but I omit
them, since they take no evident part in the reparative process, and are, as yet, not clearly
aaiftrtained.
186 HEALING OF DIVIDED NERVES.
and to fail, through excess of that disease, by a measured amount of
which the security of the artery is achieved.*
The Healing of Divided Nerves may be accomplished in two methods,
which may be named, respectively, primary and secondary union, and
may, probably, be compared with the processes of primary adhesion (p.
135), and of connexion by intermediate new-formed bonds (p, 177).
I know no instances in which nerves healed in the first method have
been examined, but the nature of the process may be explained by the
history of a case in which it occurred : —
A boy, eleven years old, was admitted into Saint Bartholomew's
Hospital, under Mr. Stanley, with a wound across the wrist. This
wound, which had been just previously made with a circular saw, ex-
tended from one margin to the other of the forearm, about an inch
above the wrist-joint. It went through all the flexor tendons of the
fingers and thumb, dividing the radial artery and nerve, the median
nerve and artery, and extending for a short distance into the radius
itself. The ulnar nerve and artery were not injured ; the condition of
the interosseous artery was uncertain, but the interosseous ligament was
exposed at the bottom of the wound. Half an inch of the upper portioa
of the divided median nerve lay exposed in the wound, and was dbtinctly
observed and touched by Mr. Stanley, myself, and others. All sensa-
tion in the parts supplied from the radial and median nerves below the
wound was completely lost directly, and for some days after the injury.
The radial artery was tied, and the edges of the woimded integuments
put together. No particular pains were taken to hold the ends of the
divided median nerve in contact, but the arm was kept at rest with the
wrist bent.
After ten days or a fortnight the boy began to observe signs of
returning sensation in the parts supplied by the median nerve, and
these increasing, I found, a month after the wound, that the nerve had
nearly recovered its conducting power. When he was blindfolded, he
could distinctly discern the contact of the point of a pencil with his
second finger, and the radial side of his third finger ; he was less sure
when his thumb or his forefinger was touched, for, though generally
right, he sometimes thought one of these was touched when the contact
was with the other ; and there were a few and distant small portions of
the skin supplied by the median nerve from which he still derived no
sensation at all.
Now all this proves tliat the ends of the divided median nerve had
coalesced by immediate union, or by primary adhesion with an exceed-
ingly small amount of new substance formed between them. In the
* Rokitansky (B. ii. p. GIC) may be referred to concerning some events in the process
which are not yet clearly ascertained ; such as the amount to which, in some cases, the clot
may be absorbed, and the share taken by deposit from the blood producing opaque-wbiia
thickening of the inner coat of the artery.
HEALING OF DIVIDED NERVES. 187
ordinary seoondarj healing of divided human nerves, twelve months
generally elapse before, if ever, any restoration of the function is ob-
Bored ; in this case, the nerve could conduct in a fortnight, and perhaps
much less, after the wound. The imperfection of its recovery is just
what one might expect in such a mode of union. One might anticipate
thftt some of the fibres in one of its portions would fail to be united to
any in the other portion : and the parts supplied by «these filaments
would pecessarily remain insensible. So, again, one might expect that
wme of the fibres in one portion would unite with some in the other,
with which they were not before continuous, and which supplied parts
•lien from those to which themselves were destined : in all such disloca-
tions of filaments there would be confused or transferred sensations.
But, among all the fibres, some would again combine in the same con-
tinuity in which they had naturally existed ; and in these cases the func-
tion would be at once fully restored. "*"
While this case was under observation, Mr. Gatty sent me, with the
permission of Mr. Heygate, in whose practice the case occurred, the fol-
lowing particulars of a similar instance of repair.
A lad, near Market Harborough, thirteen years old, had his hand
nearly cut ofi* at the wrist-joint by the knife of a chafi'-cutting machine.
The knife passed through the joint, separating a small portion of the
eoiA of the radius and of the ulna, and leaving the hand attached to the
forearm by only a portion of integument about an inch wide, connected
with which were the ulnar vessels and nerve, and the flexor carpi ulnaris
muscle— all uninjured. The radial artery and some small branches
being tied, the hand and .arm were brought into apposition, and after
ranoving a small portion of extensor tendon that protruded, were
retained firmly with adhesive plaster and a splint of pasteboard. The
wonnd went on very well, and was left undisturbed for a week. The
warmth of the hand returned ; in ten or twelve days after the injury
there was slight sensation in the fingers, but in the thumb none was dis-
cernible till more than a fortnight had elapsed. Finally, the sensation
of the hand and fingers, and most of their movements, were perfectly
restored.
In this case, again, it seems impossible to explain the speedy restora-
tion of the conducting power of the nerve, except on the supposition that
its divided fibres had immediately reunited. We have no evidence that
new nerve-fibres could in so short a time be formed ; all the cases of
• I saw this boy again nearly a year after the injury. He' had almost perfect sensation
in all the distribution of the median nerve, except in the last phalanges of the thumb and
fofefinger. These had not decreased or changed in texture ; but they were very liable to
beoocne cold, and he came to the hospital because large blisters had formed on them. He
bad been warming his hands at an open fire, and the heat, which was not uncomfortable
to the rest of the hands, had blistered these parts, as boiling water would have blistered
haaltby ones. He had almost completely recovered the movement of his fingers.
188 HEALING OF DIVIDED NERVES.
less favorable healing show that they require a year or more for their
formation.
I need hardly add the practical rule we may draw from these cases.
It is, briefly, that we may, with good hope of great advantage, always
endeavor to bring into contact, and immediately unite, the ends of divided
nerves ; and that we need not in all such cases anticipate a long-con-
tinued suspension of the sensation and other function of the part die
nerves supplied.
The secondary healing of divided nerves presents many features
similar to that of divided tendons. A bond of new substance is formed,
which connects the ends of the retracted portions of the nerve, and in
which, though at first it is like common reparative material, new nerve-
fibres form, and connect themselves with the fibres in the portions above
and below. I need not dwell on the formation or development of this
connecting bond : the subject is amply treated in several works on phy-
siology ;* and it is thoroughly illustrated, so far as the appearances to
the naked eye are concerned, by the valuable series of preparations given
to the Museum of the College by Mr. Swan.f But the observations of
Dr. Waller^ have added some remarkable facts to those hitherto asce^
tained. Watching the process that follows the division of the glosso-
pharyngeal nerve in frogs, he has found thaf after a nerve is divided, ike
old fibres, in the distal portion, never recover their functions. They
degenerate, and new fibres are gradually formed in the whole length of
the nerve, from the place of division to the peripheral distribution.
These new fibres connect themselves with those in the connecting bond
of repair, and through tliese with the old fibres in the proximal portion
of the nerve. They are, and permanently remain, like the nerve-fibres
of the embryo : they lie between the shrivelled older fibres ; and are not
formed unless union have first taken place between the divided parts of
the nerve.
The repair of nervous centres has been comparatively little studied.
The experiments of M. Brown-Sequard§ have proved that, after complete
division of the mid-dorsal part of tlie spinal cord of pigeons, and after
division of more than half of that of guinea-pigs, the sensibility and
movements of the hinder part of the body may be almost completely
restored in about twelve months ; and that the substance by which the
injury of the cord is healed contains, with fibro-cellular tissue, abundant
• See especially MQller's Physiology, by Baly, i. 457 ; Valentin's Physiologie, i. 702 j
Hildebrandt's Anatomie, i. p. 201.
t Nos. 2 109 to 2175. All these specimens', anil the appearances of the formation of new
nerve-fibres which they display, are described and illustrated by Mr. Swan, in his " Trea-
tise on the Diseases and Injuries of Nerves." In Nos. 2 105 to 2108 in the Colle{;e Museum,
Mr. liunter has shown the formation of the bulb at the ends of divided nerves, and the
extension of nerve-fibres into it.
J London Journal of Medicine, July, 1852.
§ Comptes Rendus dc la Ifoc. de Biologic, t. i. p. 17 ; t. ii. p. 3; t. iii. p. 77.
BEALIKG OF BEIH. 189
well-fonned Derve-fibres connected with those of the cord above and
below, and sparing nerre-cells.
Schrader's experiments of diriding and removing small portions of the
earrical ganglia, and the ganglion of the vagns, of rabbits, found miion
bj fibroos bonds, but no regeneration of ganglion-cells after eleven
weds.* Valentin's rimilar experiments had scarcely a more positive
re«ilt.t
After wonnds and losses of substance of the brain, a large qoantity of
new material may be formed to fill np the gap •,% but observations are
noting to show how much this may contain of proper cerebral sub-
Manoe. I have found nerve-fibres in it after thirty-^ee years (see p.
66) ; bnt in the same specimen there was no appearance of gray matter.
The last tissue to the healing of which I shall particularly refer, is the
din. I need not indeed describe the whole process, because nearly all
that was said of the healing processes generally Was chiefly illustrated
by inatances of wounds involving the skin. Yet it may be useful to
indiflftte the skin as, on the whole, the part which, being most exposed to
injury, is capable of the best repair ; that which heals most commonly
by the immediate union, most quickly by primary adhesion ; that which
produces the most rapidly and securely organizing granulations. The
healing of skin is further favored by its extensibility and loose connexion
with a^jiieent parts ; so that, when large surfaces arc to be healed, the
cratraoting granulations can draw over their borders the loose skio
around. Moreover, the new-formed skin imitates the old skin very well,
if we consider the complexity of its structure. I am not aware that the
tmooth moscnlar fibres, or any of the glandular structures of the skin,
are formed in its scars ; but its fibro-ccllular and clastic tissues, its
papillae and epidermis, are all well-formed in them. It is commonly said
that the smoothness of a scar is due to the absence of papillie, bnt I
believe it depends only on the tightness of the new-formed skin, and its
want of such wrinkled and furrowed lines as naturally exist. If a thin
section be made of the border of a healing wound, so as to include the
new-formed layer of epidermis, the
granulations now skinned over will be "*' ^
found, as in the annexed diagram (fig ~ .^^
26, a), presenting the papillary form ^ t^*
Thej consist still of nucleated cells,
but the shape of papilla is acquired,
or, rather, is retained , for the likeness I j \\
of a granulatmg surface to a finely // V
papillaty one is evident, and may be
regarded as an example of the general tendency of new-formed struc-
* SiperimeiitB circa Regenecationem in GaDgliis nerveia. Goitingen, IBSO.
t Phyiiologie, L 703,
X See especially Amemanii ; Ter»iiche Ober dai Gehim and Backenmark. Goitingen, 1787.
190 HEALIira OF sein.
tores, even in disease, to asanme a plan of constrnctian Bimihr to that of
the adjacent, parts. The likeneaB ex-
"■""■ tends to the arrangement of the
bloodvessels ; and the papillary strnc-
tore is not lost io the Uter deTelopmcot
of the scar. If the epidermis oS a
scar be separated, its under Borfiwe
will present a series of depi^eaaiofli
corresponding with the eleTations of
the papillse on which it was adapted.
The adjoining sketch represents tha
nnder surface of epidenms so reflected
from a scar on the arm of a negro :
and may illustrate not only the plan at
the papillse, of which it was like a
mould, but, by its color, the completa
reproduction of a rete nigrum.*
In concluding the lectures on Repair, and before beginning those on
Inflammation, let me briefly state the relations of the one prooeu to
the other.
It is not because we have any well>defined idea of inflammation diat
it is desirable to refer to it, as if it were a standard with which w
might compare other organic processes; bnt such a reference seeai
necessary, because some idea of inflammation mingles itself with neariy
everything that is considered in surgical pathology. Nowhere is thii
more manifest than in wimt has been written in surgical works upon the
methods of repair ; concerning which a general impression seems atiB to
be, that a process of inflammation forms part of the organic acts bj
which even the smallest instance of repair is accomplished.
Now the processes we have traced appear to warrant these general
conclusions : —
1. In the healing of a wound by immediate union, inflammation fmns
no necessary part of the process ; rathor, that its presence always hin-
ders, and may completely prevent it. The healing by immediat« nnion
should be a simple r^oining of the severed parts, without the prodoe-
tion of any new material ; and in the same proportion as, in any case,
inflammatory matter is efi'used, either in or between the wounded parts,
* For the riirthei stud; of itie heating process, esjiecioUy in the tissues and orgvu ool
mentioned in thia lecture, I inust refer ihe reader eiilier to special trealisei On the palholoQ
of those parts, or to Che chief works on General Anntoniy, especinlly in relation to all bnl
microscopic observations, to thai of Hildebrandi, edited by E. H. Webei; and to the chap-
ter* on Reproduction in Mullet's Physiology, by Baly, vol. i. p. 440, and in Talentis'i Phj-
■iolt^ie, i. TOO. The jiower of repair in the cornea is illuslmteil especially by Dr. Big|er,
in the Dublin Journal of Med. Science, 1837 ; ami by DonJers, in tJie OndeTzoekiogea
iler Uttoohticho Hoogeschool, D. i. p. 31, — The repair of fraclured teelh by bone i* de-
scribed by Mr. Tomes in bis " Dental SutRery.' The Museura of the College haa iha bed
specimens illualratin); repair, that I am aci[uainted with.
HEALING OF ifKIN. 191
in that proportion does the healing deviate from the true and best pro-
ecBB of immediate union.
2. For subcutaneous wounds and injuries, as in divided tendons, simple
fractures, and the like, nearly the same may be said. Inflammation is
excited by the local injury, but its products form no necessary part of
the material of repair ; rather, the more abundant they are, the more
icute the inflammation is, and the longer it continues, the less speedy
and the less perfect is the process of repair. For here the necessary or
best reparative material is a substance which is produced without the
signs of co-existent inflammation, and of which the development is dif-
fierent from that of the inflammatory products that are mingled with it.
And this, which is most evident in the case of the healing of subcutane-
ous injuries by bonds of connexion, is probably equally true in the case
of subcutaneous granulations.
8. In the healing of a wound by primary adhesion, or by open granu-
lations, we, usually, have evidence of a process of inflammation, in the
first instance, in the presence of its ordinary signs, in a degree generally
proportioned to the severity and extent of the injury.
4. Still, in these cases, the signs of an inflammatory process are often
absent ; and even when they exist, the process appears necessary for no
more than the production of the organizable matter, and, in the case of
granulations, for the production of only the first portions of it. The
right formation of the cells, and, yet more evidently, their higher orga-
nisation into celltQar and other tissues, ensue only while the signs of
inflammation are' absent. They are manifestly hindered or prevented
when signs of inflammation are present, or when its existence may be
suspected in consequence of the presence of some irritation, as a foreign
body, dead bone, or the like. The continuance of suppuration, also,
during the process of healing, is no proof of the continuance of inflam-
mation, if the account that I have given of pus be true.
In these two modes of healing, therefore, we may conclude that in-
flammation is sometimes absent, and is, in any case, only partially, and
at one period, requisite ; and that, in regard to it^ requisite degree, the
least amount with which an exudation of lymph is possible^ is that which
is most favorable to repair.
5. For the process of healing by scabbing, the absence of inflamma-
tion appears to be essential : indeed, the liability of our own tissues to
the inflammatory process, and to the continued exudation that it pro-
duces, appears to be that which prevents their injuries from being healed
as easily and surely, by the scabbing process, as nearly all open wounds
are in animals.
Lastly, in certain cases, the artificial production of an inflammatory
process is necessary for repairs for which the natural processes are in-
sufficient or insecure. Among these, are the cases of fractures remaining
disunited, and of arteries and veins needing ligatures.
Such may be regarded as the relations of the reparative process to
192 phenomen\ of inflammation.
that of inflammation, as it is commonly miderstood ; but, I repeat, such
a comparison can be made only for the sake of deference to the general
state of opinion in matters of surgical pathology. In truth, we know
less of inflammation than of the reparative process.
LECTURE XIII.
PHENOMENA OF INFLAMMATION.
It is no more than the truth which Mr. Travers has well expressed m
his work on the ^^ Physiology of Inflammation and the Healing Procegs"
— ^Hhat a knowledge of the phenomena of inflammation, the laws by
which it is governed in its course, and the relations which its several
processes bear to each other, is the keystone to medical and surgical
science."
I shall not attempt to define inflammation in any set terms ; for aa
yet wc are not, I think, in a position to do this. Just definitions cannot
be made in any science till some of its broad and very sure principles
have been established. Such principles we cannot boast to h^ve yet
attained in the study of pathology ; and the attempts at precise defini-
tions that have been made hitherto, seem to have led to confusion, or to
false and narrow views of truth. Besides, to define inflammation is tbe
less necessary, because, practically, we all know suflSciently well what
the term implies : we know the signs of the presence of the disease in
all its chief forms ; and, when we watch these signs in any external part,
we see them so often followed by peculiar changes in the part, that we
are justified in recognising the changes as efiects of inflammation, and
in believing that wherever wc find them, the similar or corresponding
signs of inflammation have preceded them.
But the very diflSculty of exactly defining the process of inflammation
may be our guide to the most hopeful method of investigating it. When
we see such gradual transitions from the normal process of nutrition to
the disease of inflammation, that we cannot draw a definition-line between
them, wo may be sure that the main laws of physiology are the laws alike
of the disease and of the healthy process; that the same forces arc
engaged in both ; and that, though interfered with by the conditions of
the disease, they are not supplanted or annulled.
Now, such transitions from the normal processes to that of inflamma-
tion are not rare. We may trace them, for example, in the gradual
passage from the active exercise of the brain, or of the retina, to its
" irritation " when overworked, and thence to its complete inflammation
STATE OF THE BLOODVESSELS. 198
nd impainnent of stracture, after long exposure to what had been a
itoral stimulus, or to what, in a less degree, might be so. Or, on the
itroduction of medicines, such as certain diuretics, into the blood, we
tay trace gradations from the normal increase of the functions of the
idbeys, under what is regarded as no morbid stimulus, to their intensest
iflammations. Or, again, in the application of an abnormal stimulus,
leh as that of a heat greater than the natural temperature of the body,
here shall we mark the line at which inflammation begins to supervene on
ealth ? We may, indeed, say that stagnation of blood, or effusion of liquor
iDgoinis, or some exudation, or some degenerative change in the elements
F the affected tissue, shall be the condition sine qud non of inflamma-
ion; we may call whatever falls short of these, ^^ active congestion,"
irritation," or by any other name ; but, in reality, such distinctions are
ften impossible, and sometimes untrue, and in study, the terms are con-
enient for the sake of brevity rather than of clearness.
Evading, then, the question of the precise definition of inflammation,
shall endeavor, first, to describe the state of an inflamed part, giving
9 the description such a plan and direction as may best help the chief
Mgn — ^first, of contrasting the inflammatory with the normal method
f nutrition; and, secondly, of showing that the immediate causes, and
he chief constituents, of the inflammatory state are to be found in al-
BFBiions of those things which are necessary conditions of the healthy
nbition of a part. It will be easy to connect with such a description
he explanations, so far as they can be given, of the constituent signs or
lieiiomena of inflammation, — the redness, swelling, heat and pain, and
he disturbed function of the part.
The conditions of the healthy maintenance of any part by nutrition,
are, as illustrated in former lectures (p. 26) — 1st, a regular and not far
listant supply of blood ; 2d, a right state and composition of that blood ;
id (at least in most cases), a certain influence of the nervous force ; and
tth, a natural state of the part in which nutrition is to be effected. All
hese are usually altered in inflammation.
L The supply of blood to an inflamed part is altered, both by the
famnges of the bloodvessels, especially by their enlargement, and by the
node in which the blood moves through them.
The enlargement of the bloodvessels is, I suppose, a constant event in
be inflammation of a part ; for, although in certain parts, as the cornea,
he vitreous humor, and the articular cartilages, some of the signs or effects
f inflammation may be found where there are naturally no bloodvessels,
^et I doubt whether these ever occur without enlargement of the vessels
f the adjacent parts, and especially of those vessels from which the dis-
lesed structure derives its natural supply of nutritive material, and which
nay therefore be regarded as its bloodvessels, not less than those of the
Murt in which they lie. Thus, in inflammation of the cornea, the vessels
18
194
FHSKOUBHA OF IKVLAHHAIIOH:
of the Bclerotica and conjunctiva arc enlarged, and in ulceration of arti-
cular cartilages those of the surrounding sjnoTial membrane or Bubjacent
bone.
The enlargement uaosUy affects alike the arteries, the capillaries, and
the veins, of the inflamed part; and usually extends to some distance
bejond the cbief seat or focus of the
inflammation. To it we may aseriJit
the most constant visible sign of inflaia-
mation, the redness, aa well as mitdi of
the swelling. Ita amount is varions ; it
may be hardly perceptible, or it may
increase the vessels to two or tluee
times their natural diameter. ElxtreiM
enlargement is admirably ahown in
Hunter's specimen* of the two ears of
a rabbit, of which one was inflamed bj
thawing it after it had be«n froKS.
" The rabbit was killed when the eir
was in the height of inflammatiai,
and, the head being injected, ^e two
ears were removed and dried." A
compariBon of the ears, or of the draw-
ings from them (Fig. 28), shorn all dw
arteries of the inflamed ear three or four
times larger than those of the healthj
one, and many arteries that in the
healthy state arc not visible, arc, in the inflamed state, brought oleai^
info view by being filled with blood.
I have repeatedly seen similar enlargements of both arteries, and veinB,
and capillaries, in the stimulated wings and ears of bats. The like pha-
nomena occnr in the webs of frogs, and other cold-blooded animals ; bat
in these, I think, the amount of enlargement is generally Ie8a.t
The redness of an inflamed part always appears more than is propor-
tionate to the enlargement of its bloodvessels ; chiefly, because the red
corpuscles are much more closely crowded than they naturally aro in tlte
bloodvessels. The vessels of an inflamed part are not only dilated, bat
appear crammed with the red corpuscles, which often lie or move as if no
fluid inter\'ened between them : their quantity ia increased in far greater
proportion than that of the liquid part of the blood.
This peculiarity is even more manifest in the frog than in the bat; tot
■ Museum of the College, No. 71. See, alio, Hunters Works, vol. lii. p. 333, and pL xz.
't' Emmert, who is amon;; Ibe few ihet have meBaured it, says it ia equal to ooo-half n
one-third of the noiiriBl diametei of the vessela. Lebcit says one-siltb 10 onc-Ihiid (GaMiM
Medicals, Mai 15, 1853.)
8TATB OF THE BLOODVESSELS. 195
in the fomier, the crowding of corpuscles may occur in vessels that appear
to have undergone no change of size on the application of the stimulus.'*'
Another, but a minor, cause of the increased redness of the inflamed
piart, 18 sometimes to be observed in the oozing of the coloring matter of
the blood-corpuscles, both into all the interspaces between them, and
diroiigh the "mils of the small vessels into the adjacent tissue. During
life this may be noticed, especially when the blood is stagnant in the
feMclSy and it may give them a hazy, ruddy outline ; but it is generally
mnA more considerable after death, when we may ascribe to it no small
portion of the redness that an inflamed part may still present.
In the state of inflammation no new bloodvessels are formed. Many
neve may come into view than were at first seen in the part ; but these
ue only such as were invisible till the flood of blood-corpuscles filled
and distended them. So it was in the rabbit's ears ; in the healthy ear
no trace can be seen, with the naked eye, of any vessels corresponding
with one of the largest, or with many of those of inferior size, in the
inflamed ear. So it is, too, in microscopic examinations. Within half
Ml hour after stimulating a bat's wing, many vessels may come into
▼ieir wUeh could not be seen before by the same lens^ and with which
none can be seen corresponding in the other wing, though doubtless such
vesseb exist there of smaller size.
It is only when the inflammation has subsided, and the lymph exuded
from the bloodvessels begins to be more highly organized, that new
Tanels are formed, and pass into the lymph, as if for the maintenance
of its increase or development.f So long as the inflammation lasts, the
intensest redness in parts naturally colorless,— even such as we see in
acute inflammation of the conjunctiva, or yet more remarkably in those
of periosteum,! or in congestion of the stomach, — is due to the enlarge-
ment of the natural bloodvessels to their admitting crowded red cor-
poBcles, and in a much less degree, and, perhaps, in only certain cases,
to the difiusion of the coloring matter of the blood.
With the enlargement of the bloodvessels a change of shape is com-
monly associated. Being usually elongated as well as dilated, they are
thrown into curves and made more or less wavy or tortuous. Thus we
may see the larger vessels in an inflamed conjunctiva, and, more plainly,
* I do not more particularly refer to what is described as the encroachment of the red
blood-corpuscles on the lymph-space, or the layer of fluid that lies in apparent rest adhering
ID the walls of the vessels. The too pointed description of this layer has led to exaggerated
DOtioos concerning it Its existence is certain, but it is too thin for any blood-corpuscle to
lis at rast io; and when white corpuscles remain by the walls of the vessels, it is evident
that they do so more because of their own adhesiveness than because a small portion of the
flnid about them is at rest.
t Mr. Hunter held this opinion ; but more lately the contrary one has been commonly
held. See his Works, vol. iii. p. 322.
X As illustrated in Mr. Stanley's plates ; plate vii. fig. 1, which represents a specimen in
die Museum of St Bartholomew's, Series i Na 195. The whole inner surface of the
inflamed periosteum of a tibia is bright scarlet
196
PHEITOHEHA OF INPLAXXATIOH:
the sabperitoneal arteries in cases of peritomtis ; ao, too, they are
represented in the inflamed rabbit's ear.
A more remarkable change of shape of the small vesBels of inflamed
parts is that in which they become aneurigmal or Ttuicose. The fint
observations of this state were published, I believe, by Eolliker and
Haaae, in an account of a case of inflammatory red softening of the
brain, in which many of what, at first sight, appeared to bo points of
extravasated blood, proved to be dilatations of capillary veasels filled
with blood. After this they found the same changes, but in a mnek
less degree, in some cases of inflammation artificially exdted in ^
brains of rabbits and pigeons.* Many, as well as myself^ have nnoe
made similar observations, most of which, however, seem to show, thtt
the peculiar dilatation has its seat in the small arteries and veins, as wd
as in the capillaries of the infiamed part.
Among the various forms of partial dilatation, some are like gradtul
fitsiform dilatations of the whole circumference of the vessel ; some lilu
shorter and nearly spheried
^'' ^ dilatations of it ; some like
round, or oval, or elongated
pouches, dilated from <m
side of the wall : in shor^
all the varieties of fom
which we have long recog-
nised in the aneurisms ud
aneurismal dilatations of
the great arteries may be
found in miniature in the
small vesBsels of such in-
flamed parts. SomeoftheM
forms are represented in fig:
29, from the small vessele
of an inflamed pericardima.
Frequently, however, as this state of the small vessels has bea
observed in infiamed parts (and I believe some measure of it may be
found in the infiammations of most membranes),t yet, I think, we may
not assume it to have a necessary or important connexion with the othv
phenomena of inflammation. It is often observed, as Virchow^ eepecially
has shown, in other, besides inflammatory, diseases ; and in all alike^
may be referred to a gradual deterioration of the structure of the
vessels, weakening them, and rendering them unable to resist the
* Zeilichr, IHr wisienach. Zoologie, B. i. p. 3G3. Mr. Kteman bsd obwrred ihe mat
changes some yean previousli^. See Dr. Williami's Principle* or Medicine, Sd edit. p. 381.
t LebcFi gaya it is b constant occurrence in experimental infianiinalioii* of the subcDt»
Dcoua tinme of [rngB. Gazelle Medicals, Mai 32, 1853.
1 In his Archiv, B. iii. p, 433.
* BTATE OF THB BLOODVBSSELS. 197
miformly increased pressure of the blood. Perhaps, in some cases,
u Mr. Qnekett has suggested to me, the punch-like dilatations may
represent a distorbed effort for the production of new bloodvessels by
dilatation, or outgrowth of the walls of those already extant.
Snoh is the ordinary state of the bloodvessels of an inflamed part ;
aD dilated and elongated, tensely filled with blood, of which the red
eorpnfloles are in excess, often wavy and tortuous, and sometimes
variously aneurismal.
But the supply of blood to an inflamed part is affected by its mode of
movement, as well as by the size of the bloodvessels : this, therefore, I
must now describe.
Nearly all the observations hitherto recorded, on the morbid changes
in the movement of the blood, have been made with the webs of frogs ;
and it has been objected that it is not safe to apply conclusions drawn
from them to the case of warm-blooded animals. I have therefore em-
ployed the wings of bats, in which (when one has acquired some art in
quieting them with chloroform or gentle management) nearly all the
jAenomena of the circulation, as affected by the application of stimuli,
may be watched as deliberately as in the frog, and in some respects even
more clearly.
I think we may believe that what may be seen in the wings of bats
oocors, in the lUce circumstances, in all warm-blooded animals. It is
true that, like the other hybemants, the bats, while they are in their
winter-deep, resemble the cold-blooded animals, in that their tempera-
ture is conformed to that of the external air, and scarcely exceeds it.
It is true, also, that when they are ill nourished, their temperature, even
in their active state, is comparatively low, ranging from 65° to 80° F.,
in an atmosphere of 60° ; and that* generally they are liable to much
greater diversities of temperature than our own bodies are.* And the
* For instance, I found the temperature of a strong and active Noctule-Bat (Vapertilio
Nodula) thus yarious in two days : —
April 29th, at noon, aAer he had been nearly two hours under the influence of chloroform,
and on awaking had been struggling very actively, his temperature was 09° F. At 9 p. M.,
having sometimes been quiet, hanging by his hind feet, and looking sickly, his temperature
was only 70°. When disturbed he became very fierce and active, shrieking and biting the
bars of his cage ; and at 9h. 40m. his temperamre was 92°. Soon after this he became
qaiat again, and at lOh. 30m. his temperature was 80°. The temperature of the atmosphere
daring these examinations had gradually increased from 61° to 67°. — April 30th, at 8 a. m.,
be was feeble, but not torpid : the temperature of the room during the night had been
between 40° and 45°, and was now 67° ; the temperature of the bat was only 59°. At
11 A. M., after struggling violently for half an hour, it rose to 69°. After being long under
cblorQibrm, and nearly dying, he remained all the afternoon only one or two degrees
wanner than the atmosphere. But at night, at 12h. 15m., he recovered and became active;
and, while the atmosphere was at 65°, he was at 85°. At 12h. 40m., after being made very
fieice, be was at 88° ; and at Ih. 30m. remained at 85°. Next morning he was again
•carcely wanner than the atmosphere. The temperature was always taken with a small
diermometer applied to the surface of the abdomen.
198 PHENOMENA OF INFLAMMATION:
remarkable condition, discoyered by Mr. Wharton Jones,* that those
veins in the wing that have valves contract with regular rhythm for the
acceleration of the venous stream, may affect in some measure the
morbid as well as the normal movement of the blood. Still, since in
the development of their nervous system, and the commensurate develop-
ment of their heart and respiratory organs, and in the close reoiprood
relations in which these act, the bats resemble the other warm-blooded
vertebrata, we may, I think, fairly assume a close resemblance also in
their processes and conditions of nutrition.
The simplest effects upon the bloodvessels are produced by a slight
mechanical stimulus. If, as one is watching the movement of blood in a
companion artery and vein, the point of a fine needle be drawn acroBB
them three or four times, without apparently injuring them or the mem-
brane over them, they will both presently gradually contract and close.
Then, after holding themselves in the contracted state for a few minutely
they will begin again to open, and, gradually dilating, will acquire a
larger size than they had before the stimulus was applied-f
Simple as this observation is, it involves some cardinal facts in oiiir
pathology. It illustrates, first, the contractile power of both arteriee
and veins ; it shows that this is possessed by the smallest, just as it is by
the larger, vessels of both kinds ; and, by the manner of their contrac-
tion, which follows at some interval after the application of the stimnlDS,
and is slowly accomplished, it shows that their power of contraction is
like that of parts with smooth or organic muscular fibres.
But, again, the experiment shows the vessels reopening and becoming
wider than they were before ; either yielding more to the pressure of the
blood which previously they resisted with -more strength, or else dilat-
ing, as of their own force, with that which Mr. Hunter called active dila-
tation, and compared with the act of dilatation of the os uteri. In
whichever way the dilatation is effected, whether it be active or passiTe,
the vessels will not at once contract again under the same stimulus as
before affected them. The needle may be now drawn across them much
oftener and more forcibly, but no contraction ensues, or only a trivial
one, which is quickly succeeded by dilatation. Yet with a stronger sti-
• Philos. Trans. 1852, Part L
t Some doubt must exist as to the contraction of the veins here described ; for Mr. Whu^
ton Jones has not been able to convince Iiimself of it. He considers, also, that in the frog't
web the veins are capable of but slight variation in diameter through the operation of con-
tractile power; and this accords with £. H. Weber's observations (Mailer's Archiv, 1847).
I^bert, on the other hand, expressly says that he lias observed the same various states of
contraction in the veins as in the arteries of the frog's web. In most other points relativa
to the condition of the bloodvessels, and the movement of the blood in them, my observa-
tions accord with those which Mr. Wharton Jones had completed, but not published, when
the lectures were delivered. The reader may, however, find in his admirable essay (Guy's
Hospital Reports, 1850) many minute details which I had not learned, and many illustra-
tions of singular beauty and accuracy. I cannot doubt that his later researches with the
bat's wing will much improve the description I have given.
8TAT1 OF THB BLOODVESSELS. 199
inch ms that of great heat, they will again contract and close.
iad sndi a contraction excited by a cautery may last more than a day,
bfore the vessels again open and permit the flow of the blood through
tkenu
Moreover, we may observe in this experiment the adapted movement
flf the blood. As the vessels are contracting the blood flows in them
aore slowly, or begins to oscillate : nay, sometimes, I think, even before
the vessels begin visibly to contract, one may observe that the blood
iiiOTes more slowly in them, as if this were an earlier effect of the sti-
mnlos : nor have I ever seen (what has been commonly described) the
iceeleration of the flow of blood in the contracting vessels. Such an
iGceleration, however, is manifest, as the vessels reopen ; and as they
dilate, so, apparently in the same proportion, does the flow of blood
through them become more free, till, at length, it is manifest that thoy
are traversed by both fuller and more rapid streams than passed through
them before the stimulus was applied. How long this state may last
depends on many circumstances hard to estimate: but at length it ceases,
tnd the vessels, and the circulation through them, assume again their*
sverage or normal state. «
Sach are the effects of the mechanical stimulus of bloodvessels.
The effects of other stimuli applied to wings of bats correspond in
kind, bat differ in degree and extent. If a drop of acetic acid, of tinc-
ture of capsicum, of turpentine, or of ethereal solution of cantharides,
be placed on a portion of the wing, or washed over it, one sees a quickly
emaing dilatation of the bloodvessels, and a rapid flow of blood through
them alL I am not sure that the dilatation is preceded by contraction.
Certainly the contraction is very slight, if it occur at all ; but the dilata-
tkm is usually much more extensive. When the stimulus has been
ipplied to only one small spot upon the wing, the whole of the blood-
Tenels in the corresponcUng metacarpal space, and even those of the
adjacent spaces, may enlarge. One might imagine that the dilatation of
Tessels was due to an increased action of the heart, if it were not that
(is I think) it is always greater at the very point to which the stimulus
was applied than in any other part of the same wing, and is never at all
imitated in the corresponding parts of the opposite wing.
The state which is thus induced by stimuli is what is commonly under-
stood by the expressions ^^ active congestion," or ^' determination of
blood," in a part It consists, briefly, in general enlargement of the
bloodvessels of the part, with an increased velocity of the blood in them.
It is, probably, just such a state as this that is felt by suckling women in
what they term the " flow of milk." It seems to bo an increased flow of
blood in the mammary gland just before a quicker secretion of the milk.
Leas normally, it is such a state as this that we observe in the skin after
the application of mustard, or sharp friction, or a heat from 20° to 50*^
above its own, or, in the most striking instance, when a drop of strongest
200 PHENOMENA OF INFLAMMATION:
nitric acid is placed on the skin, and, in a few seconds, all the smroimd-
ing area seems to flush, and feels burning hot. Such, too, we may sup-
pose to be the state of the vessels of the conjimctiva, when stimulated by
dust that is soon dislodged ; and such the condition of many internal
organs, when we might doubt whether they are inflamed, or are only
very actively discharging their natural functions. Herein, indeejiy in
what I have described, is one of the pieces of neutral ground between
health and disease : a step in one direction may effect the return to
health ; in another, the transit to what all might admit to be the disease
of inflammation.
Now this transit appears to be made when the circulation, which vas
rapid, begins to grow slower, without any diminution, but it may be
with an increase, of the size of the vessels. This change one may see
in the bat*s wing. After the application of such stimuli as I have
already mentioned, the movement of the blood may become gradually
slower, till, in some vessels, it is completely stagnant. The stagnation
commences, according to Mr. Wharton Jones, in the capillaries : and first
in those which are least in the direct course from the artery to the vein
[in the stimulated frog's web] : th«ice it extends to the veins and to
the arteries.
A corresponding state of retardation of blood, leading to partial stag-
nation of it, may be well seen after such an injury as that of a fine red^
hot needle driven into or through the membrane of the wing.
The first efiect of such an injury (in addition to the charring and
searing of the membrane, the obliteration of its bloodvessels, and the
puckering of the portion of it adjacent to the bum) is to produce con-
traction of the immediately adjacent arteries and veins. They may
remain closed, or, as I have already described, after being long closed,
may again open, and become wider than they were before. This dilata-
tion follows more certainly, and perhaps without any previous contrac-
tion, in the arteries and veins at a little distance from the bum. In
these, there speedily ensues such a state of " determination of blood" as
I have already described : in arteries and veins alike the stream is full
and rapid ; and the greater accumulation, as well as the closer crowding,
of the red corpuscles, makes the vessels appear very deep-colored. The
contrast of two diagrams, showing the natural and the stimulated condi-
tions in a single segment of the vascular plan of the wing, illustrates
this difierence suflScicntly well* (Figs. 30, 31). The vessels of the one,
nearly twice as large as those of the other, darker, and more turgid with
blood ; and, in the one, numerous capillaries which are not visible in the
other. But diagrams cannot show the changes in the mode of move-
ment. Close by the burn, the blood which has been flowing rapidly
begins to move more slowly, or with an uncertain stream ; stopping, or
* The plan of vessels drawn is copied from Mr. Wharton Jones's plate. Philos. Tianii
1852, Part I.
BTATH OF THH CIBCt7LATI0IT.
fl ebbing, and then again flowing on, bnt, on the whole, becoming
jnduJly aloirer. Thus it may, at length, become completely stagnant ;
and then, in the veseels in which it is at rest, it seems to diffuse and
change its color, so that its crowded corpuscles give the vessels a bril-
liant carmine appearance, hy which, just as well as by tbe stillness of
the blood, they may always be distinguished. As one surveys an area
sorromiding this part, one sees streams the more rapid the more distant
they are from the focus of the inflammation. And often, when there is
202 PHBKOMBNA OF IKFLAMM ATIOK:
stagnation in a considerable artery, one may see the blood above or
behind it pulsating with every action of the heart, driven up to the seat
of stagnation, and thence carried off by the collateral branches ; while,
in the corresponding vein, it may oscillate less regularly, delaying till an
accumulated force propels it forward, and, as it were, flushes the chan-
nel.'*' In the area still more distant, one sees the full and rapid and
more numerous streams of ^^determination" or ^^ active congestion,"
which extend over a space altogether uncertain.
Such is the general condition of the circulation in and around a part
that is inflamed. In few words, there is, in the focus of severe inflant-
mation, more or less of %tagnation of blood ; in and close around it,
there is congestion^ — L 6., fulness and slow movement of blood ; more dis-
tantly around there is detemiinationy — i. «., fulness and rapid movement
of blood. The varieties in lesser points that may be presented cannot
be described. These must be seen ; and, indeed, the whole sight shonld
be viewed, by every one who would have in his mind's eye a distinct
image of what, in practice, he must often too obscurely contemplate.
The phenomena that I have described as seen in the bat's wing corre-
spond very closely with those observed in the frog's web. Only I think
the stagnation of blood is neither so constant nor so extensive in the
bat : it is seen in portions of single vessels, rather than in districts of
vessels ; often in corresponding portions of arteries and veins, as they lie
side by side. The stagnation usually extends into such branches as
may be given from the vessels that are its principal scats ; and three or
four such seats of stagnation may appear placed irregularly about the
burn, or other focus of the inflammation ; but I have never seen a general
stagnation of blood in all the vessels of even a severely stimulated part
My impression is, that, in strong and active warm-blooded animals, stag-
nation of blood would bo found in only the most severely inflamed parts ;
in others, I think, retardation alone would exist.f
To sum up now what concerns the supply of blood in an inflamed part.
We seem to have sufficient evidence that, in general, in the focus of the
inflammation, blood is present in very large quantity, distending all the
vessels, gorging them especially with red corpuscles, but often moving
through tliem slowly, or even being in some of them quite stagnant ; that
all around this focus, the vessels are as full, or nearly as full, as they
are in it, but the blood moves in them with a quicker stream, or may
pulsate in the arteries, and oscillate in the veins ; that, yet further from
the focus, the blood moves rapidly through full but less turgid vessels.
And this rapidity and fulness are not to be ascribed, I think, merely to
the blood, which should have gone through the inflamed part, being
driven through collateral channels, but are such a sta.te as is commonly
• What I thus described was, no doubt, the result of the rhythmical contnictioD of the
veins, which Mr. Wharton Jones has since discovered.
t M. Lcbcrt expresses the same belief: Gazette M^dicaie, Mai 22, 185*2.
BTATE OF THE CIROni«ATION. 208
miderstood as an ^^ active congestion/' or ^^determination of blood" in
the part.
I have already Guud, that we may believe that what is seen in the bat
rajpresents fairly the state of inflamed parts in all warm-blooded animals.
I am quite conscious that the most one can see with the microscope, in
these experimental inflammations, is but a faint picture of such inflam-
matioDB as we have to consider in practice ; that it is very trivial in both
its appearance and its results. Still, it is a picture of a disease of the same
kind; and a miniature, even faintly drawn, may be a true likeness. Be-
sides, all that can be observed of the complete process of inflammation
in man is consistent with what we can see in these lower and lesser
creatures. The bright redness of an inflamed part testifies to the fulness
of its bloodvessels, and the crowding of the corpuscles ; the occasional
dnskineas or lividity of the focus is characteristic of stagnation j the
throbbing of the part, and about it, and the full hard pulse in the minis-
trant arteries, are sure signs of obstruction to the passage of blood ; the
gush of blood on cutting into the tissues near an inflamed part, or in
bleeding from one of their veins, tells of the determination of the blood
in these, and of the tension in which all the containing bloodvessels are
held.
It is particularly to be observed, that the stagnant or retarded blood
is not apt to coagulate. I have found it fluid after at least three days'
oomplete stagnation, and so I believe it would remain till it is cleared
away, unless the part sloughs. In the latter case it would coagulate, as
it does in carbuncles and the like, which hardly bleed when we cut them
through, but so long as the blood is fluid, though stagnant, it may be
diiven from the vessels with full force, as soon as an easy exit for it is
made by catting into the inflamed part, or opening one of its large veins.
I need only here refer to Mr. Lawrence's well-known and instructive ex-
periment. In a patient with an inflamed hand he made similar openings
into veins in both arms. From the vein on the diseased side three times
more blood flowed than from the vein in the healthy arm, in the same
time. This increased flow represented at once the greater determination
of blood about the focus of the inflammation, and the greater tension in
which the walls of the bloodvessels, and, indeed, all the tissues of the
inflamed and swollen part, were held.
Now, to what can we ascribe these changes in the movement of the
Uood?
It has been commonly said that, as the vessels contract, therefore the
movement of blood becomes more rapid in them, as when a river entering
a narrow course moves through it with a faster stream ; and that then,
as the vessels widen, so the stream becomes, in the same proportion,
slower. But this is far from true. The stream becomes slower as the
srtery or vein becomes narrower by contraction ; and then, as the tube
again dilates, the stream grows faster ; and then, without any appreci-
204 PHBKOMEKA OF INFLAMMATION:
able chango of size, it may become slower again, till complete stagnation
ensues in at least some part of the bloodvessel.* I think I can be quite
sure that the velocity of the stream, in any vessel of an inflamed part,
is not wholly determined either by diminution or enlargement of the
channel, or by the stagnation or congestion of blood in the vessels be-
yond. That much of the change in rate of movement depends on these
conditions cannot be doubted ; and it may seem unnecessary to qnestioo
their sufficiency for the explanation of that change, after Mr. Wharton
Jones's observations. But I think other forces must still be considered,
whose disturbance may contribute to the result. Whether we name it
vital affinity, or by any other terms, or (which may, as yet, be betto*)
leave it unnamed, I cannot but believe there is some mutual relation be-
tween the blood and its vessels, or the parts around them, which, being
natural, permits the most easy transit of the blood, but, being disturbed,
increases the hindrances to its passage. Such hindrances appear to be
produced by the addition of salts of baryta, or of potash, to the blood;
and by an excess of carbonic acid in the blood that should traverse the
minute pulmonary vessels. The presence of an excess of urea in the
blood probably produces the like eifect : and some of the facts connected
with other than traumatic inflammations appear quite inexplicable with-
out such an hypothesis as this. At any rate, the belief that the more
or less rapidity of movement of blood through small vessels may depend
on other than evident mechanical relations, cannot appear absurd to any
one who has seen the movements of fluid in the Ghara or Vallisneria, or
any such plants, in which a circulation is maintained without any visible
source of mechanical power.
II. I mentioned, as the second condition necessary to the healthy
nutrition of a part, a right state and composition of the blood. Li
former lectures (p. 26, et acq.) I pointed out that, by this state, we must
understand not merely such purity of the blood that chemistry cannot
detect a wrong constituent in it, or a wrong quantity of any of the normal
ones, but that natural constitution of the blood by which it is exactly
adapted to every tissue that it has to nourish ; with an adaptation so
exact that chemistry often cannot approach to the determination of
whether it is maintained or lost.
That this adaptation is disturbed, in many cases of inflammation, is
proved by the instances to which I shall have to refer, in which they
plainly have their origin in morbid conditions of the blood. But I fear
that the nature of this disturbance cannot yet be chemically expressed,
and that the facts, which chemistry has discerned, in the condition of
the blood in inflammations, cannot yet be safely applied in explanation
* As Mr. Wharton Jones 1ms shown, the retarded stream exists only when the yessel if
generally contracted, and the accelerated stream when it is generally dilated : when a single
vessel presents successive enlargements and diminutions of calibre, the rate of the stream
in it diminishes in the former and increases in the latter.
STATE OF THE GIRGULATIOir. 205
of the local process. For, first, we obserye the phenomena of inflamma-
tkm where we cannot suppose the whole blood disordered ; as after the
a]q>lication of a minute local stimulus, such as a foreign body on the
ooigiinctiTa : secondly, the changes observed in the blood during inflam*
BMtions are not peculiar to that state, but are found more or less marked
in pregnancy, and in other conditions in which no inflammatory process
taoBts : and, thirdly, among the changes observed in inflammatory blood,
die principal one, namely, the supposed increase of fibrine, is ambiguous ;
It may be at once an increase of fibrine and of the white corpuscles of
the blood. These two constituents of the blood, the fibrine and the
white or rudimental corpuscles, cannot be well separated by any process
jet invented ; and in all the estimates of fibrine, whether in health or in
disease, the weight of the white corpuscles is included. Now in many
ioflanunations these corpuscles are increased ; and in such cases we have
no means of clearly ascertaining how much of an apparent increase of
fibrine is really such, and how much is due to the corpuscles entangled in
the 'fibrine. Till this can be settled, I think we may not deduce any
of the local phenomena of inflammation from the increase of fibrine in
the blood ; neither, more assuredly, can we trace, as some do, the fever
and other general signs of inflammation to the abstraction of fibrine and
albumen by the exudation from the blood.
The other principal changes of the blood in inflammation — ^the dimi-
nntion of its red corpuscles and increase of water — are even less adapted
to explain any of the phenomena of the local process. Whatever may
be their strength or value as facts, they are as yet isolated facts, such as
we cannot weave into the pathology of the disease.
I fear, too, that the structural condition of the blood will not, more
than the chemical, help us to explain the phenomena of inflammation.
Some of our most worthily distinguished pathologists have ascribed much
to the existence of large numbers of the white blood-corpuscles, and
their accumulation in the vessels of the inflamed part ; indeed, they have
taken this for the foundation of nearly their whole doctrine of inflam-
mation, ascribing to it both the stagnation of the blood and the changes
it is presumed to undergo ; such as the increase of the fibrine, and many
others. But the facts on which they have rested are unsound : their
observations have been made on frogs, and do not admit of application
to our own case, or, perhaps, to that of any warm-blooded animal.
In many frogs, especially in those that are young, or sickly, or ill-fed,
the white corpuscles are abundant in the blood. They are rudimental
blood-cells, such as may have been formed in the lymph or chyle ; and in
these cases they are probably either increasing quickly in adaptation to
quick growth, or else relatively increasing because, through disease or
defective nutriment, although their production is not hindered, yet their
development into the perfect red blood-cells cannot take place. In
either case, their peculiar adhesiveness making them apt to stick to the
206 PHENOMENA OF INFLAMMATION:
walls of the bloodvessels, they may accumulate in a part in which the
vessels are injured or the circulation is slow, and thus they may 8om^
times augment the hindrances to the free movement of the blood. Bat
I believe nothing of the kind happens in older or more healthy frogs, or
in any ordinary inflammation in the warm-blooded animals. I hafe
drawn blood from the vessels in the inflamed bat's wing, in which it wis
quite stagnant, and have found not more than one white corpuscle to
5000 red ones. I have often examined the human blood in the vessels
of inflamed parts after death, and have found no more white corpuscles
in them than in those of other parts. In blood drawn from inflamed
parts during life, I have found only the same proportion of white co^
puscles as in blood from the healthy parts of the same person. I there-
fore cannot but accord with the opinion, often expressed by Mr. Whartoi
Jones and Dr. Hughes Bennett, that an especial abundance of white
corpuscles, in the vessels of an inflamed part, is neither a constant nor
even a frequent occurrence ; and I believe that, when such corpuscles
are numerous in an inflamed part, it is only when they are abundant in
the whole mass of the blood.'*' Now, as already stated, they are thus
abundant in some cases of inflammation ; especially, I think, in those
occurring in people that are in weak health, and in the tuberculous ; but,
even in these cases, I have never seen an instance in which they wen
present in sufficient quantity to add materially to the obstruction of the
blood in the inflamed part, nor one in which any influence of theirs oould
be suspected to alter peculiarly the constitution of the blood therein.
Mr. Wharton Jones was the first to describe accurately a remarkable
condition presented by the red blood-cells in inflammation. Wh<m
healthy blood is received on a glass plate and immediately examined, the
corpuscles lie difiused in the liquor sanguinis, but in about half a minute
run together into piles or rouleaux, which arrange themselves in a small-
meshed network, as in the following figure (a). But, if a drop of blood
from a patient with acute rheumatism or inflammation be similarly
examined, the piles of corpuscles are found to be instantly formed, and
they cluster into masses, in a network with wide meshes, as in the same
figure (b). In such an arrangement they give the thin clot outspread on
the glass the peculiar mottled pink and white appearance, which Mr.
Hunter observed as one of the characters of inflammatory blood. The
same condition is observed in the blood of pregnant women, and appears
natural in that of horses ; and in all these cases it may be regarded as
the chief cause of the formation of the bufiy coat, inasmuch as the
clustered blood-cells, sinking rapidly, generally subside to some distance
below the surface of the liquid part of the blood, before the coagulation
of the fibrine is begun.
* Dr. Hughes Bennett^s researches on Leucocythoemia have shown that even the ex-
tremest abundance of white corpuscles in the blood has no tendency either to produce or to
aggravate inflammations.
STATB OF THE BLOOD.
ime have sapposed that a BimilBr adhesion of the blood-cells may
r in the TeewlB of an inflamed part, and produce, or materially
tfieet, the inflammatory process. I have seen nothing of the kind in either
the infl&med bat's niiig, or in the vessels of inflamed organs examined after
death. When the blood is not stagnant, the corpuscles are indeed closely
crowded, bat tbey are ndt clustered, nor do they appear adherent f
neither does snch clustering appear even in stagnant blood ; the change
here spears to be a diffusion of the coloring matter, so that the outlines
of individnal blood-cells cannot be seen, and all the contents of the
veesel present a uniform bright carmine tint.
Bat although ve can see bo little of the changes that may ensne in
blood tbns stagnant or much retarded, yet we may he nearly sure that
the blood in an inflamed part does undergo important changes, when
we remember what general effects, what constitutional disturbaiice, may
cosoe in the trun of an inflammation of purely local origin. Changes
probably ensne in the blood similar to some of those that we shall have
to trace in the lymph effused from it into the parts around the vessels ;
particles of fibrine may coagulate in it, and corpuscles like those of
lymph may be formed and degenerate within it ; and these, when the
stagnation is not constant, or is incomplete, or is passed away, may be
carried into the general circulation, infecting the whole blood, exciting
general disturbance, as in traumatic fever, or producing various and
wide-extended sappurationB, as in the purulent diathesis following local
injury. All these, and many other concomitants of inflammation, may
be reasonably ascribed, at least in part, to the changes that the blood
undergoes in the inflamed tissue ; but I must repeat that nothing that
either the microscope or chemistry has yet discerned will suffice to
explain these changes : they belong rather to the theory than to the
facta of inflammation.
208 PHENOMENA OF INFLAMMATION:
III. The third enumerated condition for the healthy natrition of a
part is a certain influence of the nervous force. The change that this
undergoes in an inflamed part is, therefore, next to be considered ; or,
rather, the evidence that it is changed is to be cited; for, as we have no
exact knowledge of the manner in which the nervous force operates in
ordinary nutrition, so neither can we tell how its operation is affected in
infli&mmation, though we may be sure that it is not normal.
The expression that the nerves of an inflamed part are in an ^^ excited"
state, is suggested by the existence of pain ; by a slight stimulus bdng
acutely felt ; by the natural heat, or a slight increase of the heat, being
felt as a burning ; and by the part being, even independent of any knoim
stimulus, the seat or source of subjective pains and heat. But the very
frequent cases in which pain exists, and abides long, without any other
sign of inflammation, and the cases in which the pain bears no kind of
proportion to those other signs, or to the effects of inflammation, — ^these
may suggest that, besides this '^ excited*' state of the nervous force
which is felt as pain in the inflamed part, there may be some ot&er state
by which the nervous force is more intimately connected jwith the inflam-
matory process ; a state of disturbance, which may indeed be felt tt
pain, but which more properly affects the influence of the nervous force
in the process of nutrition.
* We obtain some evidence of the existence of such a state in the fact
that, without relation to pain, it is communicable from the nerves of
inflamed parts to those of other parts ; in which parts, then, a kind of
sympathetic inflammation may be generated. This transference or com-
munication of the disturbance of nervous force is, indeed, evident enough
in relation to that state which is felt as pain ; for pain is not limited to
the inflamed part but is diffused around it, and is, in sympathy, often
felt where no other sign of inflammation exists. But besides, and some-
times, I repeat, independent of this condition which is felt as pain, the
inflammatory condition, if I may so name it, of the nervous force, may be
similarly commimicated or transferred. The simplest may be the most
proving instances. Whoever has worked much with microscopes may
have been conscious of some amount of inflammation of the conjunctiva,
in consequence of over-work. Now the stimulus exciting this inflamma-
tion has been directly applied to the retina alone ; and I have often had
a slightly inflamed left conjunctiva, after long working with the right
eye, while the left eye has been all the time closed. I know not how
such an inflammation of the conjunctiva can be explained, except on the
supposition that the excited state of the optic nerve is transferred or
commimicated to the filaments of the nerves of the conjunctiva, genera-
ting in them such a state as interferes with its nutrition. It is true that,
in these simpler cases, the retina is not itself evidently inflamed ; but
after yet severer stimulus it commonly is so, and the conjunctiva shares
in the evil effects of the communicated stimulus ; effects which we can-
not ascribe to any alteration in the blood, or the size of the bloodvessels.
BTATB OF THE NERVE-FORCE. 209
may mention another case ; the occurrence of inflammation of the
jle in cases of severe irritation of the urethra. The most unexcep-
J>le cases of the kind are those in which the irritation is produced
ealcnluB impacted in a healthy urethra. I have a specimen,* in
h extensive deposits of lymph and pus are seen in the testicle of a
, in whose urethra a portion of calculus was impacted after lithotrity.
9 is such an inflammation as we cannot refer to disease of the blood,
attended by such changes as we cannot explain by any enlargement
•ralysis of the bloodvessels: nor do I know how it can be at all
lined, except by the disturbance of the exercise of the nervous force
le testicle, which disturbance was excited by transference from the
Mdly affected nerves of the primary seat of irritation in the urethra.
1 like manner, I believe that the extension or transference of inflam-
km, after or with pain, may be ascribed, at least in part, to the coin-
nt transference of the disturbed plasturgic force of the nervous sys-
In paroxysms of neuralgia, we see sometimes a transient inflam-
nj^redness or oedema of the part; so, when a more abiding pain has
I excited, by sympathy with some inflamed part, there may presently
Irene the more palpable effects of inflammation.
feel that in discussing such a point as this, one passes from the
md of demonstrable facts ; but there is, I hope, less fault in this
I in the belief that the very little we can see of a morbid process can
bus to its whole pathology. When we look at an inflamed part, we
lid not think that, if we could see its bloodvessels and test its blood,
lioold detect all that is in error there : rather, we should think that
bhe forces are at fault which should be concurring to the due main-
noe of that part ; and while we are ignorant of the nature of some
heee forces, it is better that their places in our minds should be
pied by reasonable hypotheses, than that they should be left blank,
e overspread with the tinge of one exaggerated theory, such as those
which ascribe all inflammation to a change in some one of the condi-
B of nutrition.
V. The last condition necessary to healthy nutrition in a part is the
irmi or healthy state of the part itself.
lie manner in which this is changed in the inflammatory state cannot
rell considered till an account has been given of the exudation that
0 place from the bloodvessels, and of some other changes in the very
9eiB of nutrition. Let it, for the present, suffice to say (1), that a
nrbance in the condition of a part may be the cause, independently
bloodvessels or nerves, [of an inflammation in it, as in wounds and
IT injuries of non-vascular and other parts; and (2), that when an
immation is thus, or in any other way, established, the proper
* Mosenm of St Bartholomew's Hospital, Ser. xzTiiL No. 55.
14
210 PRODUCTS OF IirFLAMMATION:
elements of the affected part continually suffer change. Such changM
are due, first, to the degenerations which, as in other cases of hindered
nutrition, the elemental structures spontaneously undergo: and, secondly)
to the penetration of the inflammatory product into them and the inte^
stices between them. Each of these sources of change may, in different
cases, predominate: in certain cases, it is probable that one alone of them
may be effective; and either or both of them may affect either the
elemental structures that are already perfected, or, probably in a greater
degree, the materials that are in progress of development.
All these things will be subjects of future lectures ; but, before pro-
ceeding to them, let me add a few words, to prevent misunderstanding.
I have spoken so separately of the changes in the several conditions of
nutrition, that I may have seemed to imply that inflammation may consist
in the disturbance sometimes of one, sometimes of another, of these states.
It is true that inflammation may have its beginning in any one of these
conditions, — as in an alteration of the blood in rheumatism, in an altera-
tion of the nervous force in irritation of the retina, in an alteration of
the proper elements of the tissue in inflammation of the cornea; but}
probably, it is never fully established without involving in error all tliA
conditions of nutrition; and both the manner in which they may be
thus all involved, and their subsequent changes, should be studied as
concurrent events, rather than as a series of events, of which each stands
in the relation of a consequence to one or more of those that preceded it
Nowhere more than here is the mischief evident, of trying to discern in
the economy of organic beings a single chain or series of eyents,
among which each may appear as the consequence of its immediate prede-
cessor : most fallacious is the supposition that, starting from a turgescence
and stagnation of blood in the vessels of a part, we may explain the
pain, the swelling, the heat, and all the other early and consecutive
phenomena of inflammation, The only secure mode of apprehencUng
the truth in this, as in every other part of the economy of living beings,
is by studying what we can observe as concurrent, yet often indepen-
dent, phenomena, or as events that follow in a constant, but not neces-
sarily a consequent, order.
LECTURE XIV.
PRODUCTS OF INFLAMMATION.
The state described in the last lecture may, without further change,
cease and pass by, and leave the part, apparently, just as it was before.
And there are two chief modes in which this may happen ; namely, by
resolution or the simple cessation of the inflammation, and by metastasis,
8BBUM. 211
Jn which, while the inflammation disappears from one part, it appears in
another. So far as the inflamed part itself is concerned, I believe the
cihftnges are in both these cases the same, and consist in a more or less
Mpeedy retom to the normal method of circulation, and the normal
apparent oondition of the blood and of the nerves ; the tissue itself pre-
amtiiig no change of structure.
I do not know that any description of the process of recovery, from
the inflammatory state, would tell more than is implied by calling it a
gradual return to the natural state, a gradual retracing of the steps by
which the natural actions had been departed from. As it has been
watched in the frog's web, and in the bat's wing, the vessels, that were
filled with quick-flowing blood, became narrower, the streams in them
also becoming slower, and less gorged with red blood-corpuscles, till the
natural state is restored. The pulsating or slower streams are equalized
with those about them, and, gradually making their way into the stagnant
eolnmna, drive them on or disperse them. In the frog, clusters of blood-
eorpuscles have been seen to become detached, by a stream breaking oflf
portions of the stagnant blood, and then to float into the current, where,
gradually, they disperse. So, too, in the tadpole, after injury, I have
Been fri^ments of fibrine, washed from the blood in the vessels of the
injured part, floating in some distant vessels. Dr. Kirkes's observations
kftve no doubt that similar changes may occur in the warm-blooded
aaimalfl, and may be the source of great evil, by carrying the materials
of diseased or degenerate blood from a diseased organ to one that was
previously healthy (p. 103).
It may be difficult to explain this discovery in the case of complicated
inflammations. When a slight mechanical stimulus has been applied,
and the vessels, after contracting, have dilated, we may see some signs
of weakened muscular power, in the fact that the same stimulus will not
make them contract again ; and then their gradual recovery may be the
consequence of their regaining their weakened and exhausted power, just
as a wearied muscle does when left at rest. This must always be one
element in the recovery of the natural state by a part that has been
inflamed ; indeed, it is probably that part of recovery which is most
slowly achieved. Still, it is, probably, only one element in the process
of recovery. In an inflammation in which all the conditions of nutrition
are at fault, each must recover its normal state ; but of the manner in
which they severally do so we have no knowledge. The order in which
they are restored is scarcely less uncertain : probably it is not constant,
but may depend, in great measure, on the order in which they were
involved in error. But we have no clear facts in this matter ; only we
may observe that, in many cases, if we correct the error of one of the
conditions of nutrition, the rest will be more apt to correct themselves.
Thus, of the remedies for inflammation, few can act upon more than one
•of the conditions on which it depends ; yet they may be remedies for the
212 PRODUCTS OF ikflammation:
whole disease ; for, as it were, by abstracting one of its elements, tkcy
destroy the consistence and mutual tenure of the rest.
The cessation of the disease may be regarded as the most perfect core
of which inflammation admits. It is in many cases an unalloyed adyaa-
tage ; but in some it is not so, though the local change may be the same;
for materials accumulated in the stagnant blood of the inflamed part, or
absorbed from its morbidly altered tissues, may, when the inflammati(m
subsides, pass into the general current of the blood, and infect its whole
mass, or disturb the nutrition of an organ more important than tbtt
which they have leffc. Such are the events in the metastasis of gout,
and the premature subsidence of cutaneous eruptions.
We have now considered how, in the inflammatory state, th^ conditions
of nutrition are affected : and, in a future lecture, I hope to show how a
change in any one of these conditions may appear as the cause of inflam-
mation, by bemg the first in the series of changes in which, in the com-
plete morbid process, they are all involved.
The next subject may be the changes in the nutritive process itself;
those which are commonly observed as the effects of inflammation, when
the process does not subside in the manner just described. They are
chiefly manifest (1) in a change of the material that is separated from
the blood into or upon the affected tissue ; and (2) in changes of the
tissue itself. These changes usually coincide : and it may be general^
said, that in all inflammations, at least of vascular parts, there is at onoe
an increased exudation of fluid from the bloodvessels, and axdeterioration
of the structures of the affected part. Either of these events may, in
certain cases, predominate over the other ; in some instances, one alone
of them may be observed ; but they so generally concur, that a natural
division of the inflammatory changes of the nutritive process may be into
those that are productive and those that are destrttctive.
Adopting, then, such a division, as of the effects of inflammation, the
description of the productive changes will include the histories of the
several effusions or exudations from the bloodvessels into the inflamed
part, their developments, degenerations, and other changes. In the
account of the destructive effects may be comprised that of the various
defects of nutrition, the degeneration, absorption, ulceration, and death,
to which the proper elements of the inflamed part, and, with them, the
products of the inflammation, are liable.
I proceed, then, to these histories ; and first of the products of injUmi-
motion or inflammatory exudations.
The materials that may be effused from the bloodvessels of inflamed
parts are chiefly these : serum ; blood ; lymph, or inflammatory exuda-
tion especially so-called ; and mucus. The last two may be regarded as
primary forms, from which, by development, or degeneration, many
others may be derived.
, raised by the action of cantharides or heat applied to healthy
And another form of liquid effusion differs from serum, in that,
does not coagulate, it contains a material capable of organiza-
oells : such is the fluid that fills the early vesicles of herpes,
nd some other cutaneous diseases.
id that contains fibrine, and is most generally described as a
tsion, may have the ordinary aspect of serum ; more rarely it
s or opalescent, like the liquid part of the blood which one sees
for the formation of a buffy coat. The fibriuiS that it contains
in in solution, or without coagulation, for an indefinite time
> body, but will coagulate readily when withdrawn- For ex-
'■ so-called serous effusion, which is abundant in the integuments
eat of an acute inflammation in. deeper parts, and which flows
thin yellowish serum after death, will soon form a soft jelly-
hat is made succulent with the serum soaked in it. The fibrine
ragh, opaque-white, and stringy, when the fluid is expressed
id shows all the recognised characters of the fibrine of the
hns, to mention but one case which was remarkable for the
lie coagulation. A man received a compound fracture of the
; was followed by phlegmonous inflammation and abscesses up
As soon as the inflammation had subsided enough, the limb
tated ; and, three days afterwards, in examining it, a quantity
looking fluid oozed from the cut through the integument. I
some of this, and, after four hours, it formed a perfect fibri-
; yet the fibrine in this case had remained among the tissues
mgulating, for three days after the death of the limb^ and for
« days during the life of the patient.
214 PRODUCTS OF inflammation:
One can rarely tell why the coagulation of the fibrine in these casa
should be delayed : there are, here, the same difficulties as are in all die
exceptions from the general rules of the coagulation of the blood. But,
it may be observed, the delay of the coagulation is a propitious event in
all these cases ; for, so long as the effusion is liquid, absorption may
ensue on the subsidence of the inflammation ; but absorption is more
unlikely and tardy when the fibrine has coagulated. Thus, large quan-
tities of fluid, which we may be sure contained fibrine, may disappear by
absorption from the seats of acute rheumatism or gout, or from the
pleura or peritoneum, or from the subcutaneous tissues, and leave only
inconsiderable adhesion, or thickening of the affected part. But, on
the other hand, when, in the same class of cases, the fibrine coagulates,
it may be organized, and the usual consequent phenomena of inflammsp
tion will ensue. Thus it is in the cases of what has been called solid
oedema, where, in the neighborhood of acute inflammation, an efiusioB
long abides with all the characters of ordinary serous oedema ; but, at
length, the tissues are found indurated and adhering, the oedema having
consisted in the effusion of serum with fibrine, which has coagulated and
become organized in the seats of its effusion. Thus, too, it is that the
damage done by rheumatism in a part is, on the whole, in direct propor-
tion to the length of time it has subsisted there, and the opportunity
given by time for the coagulation of the fibrine.
From what I have said, it will appear that nearly all of what are
called serous effusions in inflammation are effusions of fluid containing
either fibrine, or a material that will organize itself into cells. But it
may be said that we often find, after death, effusions which contain
nothing but the constituents of serum, though produced in an inflamma-
tory process. If, however, we examine these cases more closely, they
will appear consistent with the others : some of the fluids will coagulate
if kept for several hours, or if mixed with other serous fluids, or if frag-
ments of fibrine'be placed in them ; in others we find flakes of molecular
matter, indicating that fibrine had been already coagulated, or that cor-
puscles had been formed, but that subsequently they were disintegrated,
or even partially dissolved ; and in some we may believe that similar
materials were decomposed in the last periods of life, or after death.
On the whole, it seems sure that an effusion of serum alone is a rare
effect of inflammation, and that generally it is characteristic of only the
lowest degrees of the disease. Among the instances of it are, probably,
the cases of the chronic forms of hydrops articuli, some forms of hy-
drocephalus, and some cases of inflammatory oedema of the mucous
membrane, as in the oedema of the glottis, and chemosis of the con-
junctiva.
In the nearly constant fact of the presence of organizable materials
in the products of inflammation, we have one evidence of the likeness
between inflammation and the normal process of nutrition, and of its
BLOOD. 215
diiference from the merely mechanical obstructions or stagnations of the
blood. In these, the material effused from the blood is usually the
merely serous part : the fluids of anasarca and ascites will not coagu-
late ; they present neither fibrine nor corpuscles, except in the cases of
eztremest obstruction, when, as in cases of ascites from advanced disease
of the heart, one may find flakes of fibrine floating in the abdomen, or
masses of it soaked and swollen-up with serum. "**
IL The second of the so-called inflammatory effusions is Blood.
Among the effusions of blood that occur in connexion with the inflam-
matory process, many, as Rokitansky has explained, are examples of
hemorrhage from rupture of the vessels of lymph recently become vas-
cular. The new vessels, or their rudiments, are peculiarly delicate ; and
being apt to rend, like the vessels of new granulations, with a very slight
force, especially when they are made turgid or dilated by an attack of
inflammation of the lymph, they will commonly be sources of conside-
rable bleeding. So, for example, it probably sometimes happens when,
as the expression is, a hydrocele is converted into an hematocele ; some
lymph becoming vascular, and being submitted to even slight violence,
its vessels break, and blood is poured into the sac. So, too, probably, it
is with many or all the cases of what are called hemorrhagic pericarditis.
But of these, which may be called secondary hemorrhages^ I will speak
hereafter.
^Primary effusions of blood, t. e.y effusions of blood poured from the
raptured vessels of the inflamed part, and mingled with the lymph or
other inflammatory product, appear to be rare in some forms or localities
of inflammation, but are almost constant in others. Thus, e,g,j in pneu-
monia, extravasated blood-corpuscles give the sputa their characteristic
rusty tinge. In the inflammatory red softening of the brain, blood is
also commonly effused ; and the condition of the vessels, which I described
in the last lecture (p. 196), may well account for their rupture. There
are also other cases of these effusions of blood in inflammation ; but I
believe these imply no more than accidents of the disease.
We must not confound with hemorrhages the cases in which the
inflanmiatory products are merely blood-stained, i. e., have acquired a
more or less deep tinge of blood, through the oozing of some dissolved
coloring matter of the blood. The natural color of inflammatory exuda-
* It has been supposed that, in mechanical dropsies, the effusion of serum takes place
through the walls of the small veins, and tliat in inflammations an equally mechanical effu-
siofi of liquet sanguinis takes place through tlie walU of the capillaries and small arteries;
and this supposition is assumed for an explanation of the difference between a dropsical
and an inflammatory effusion. But I think tliat in a merely mechanical obstruction of the
blood, as by disease of the heart, or compression of veins, the pressure of the blood cannot
hot be increased aUke in the veins, capillaries, and arteries, and that, in correspondence
with this imifonnly diffused pressure, the increased effusion will take place at once through
aU these vessels, in direct proportion to the permeability of their walls.
216 PRODUCTS OF inflammatiok:
tions is grayish or yellowish-white, and, even when they have become
^ vascular, their opacity in the recent state prevents their having any uni-
form tint of redness visible to the naked eye. When inflammatory pro-
ducts present the tinge of redness, it is either because of hemorrhage
into them, or because they have imbibed the dissolved coloring-matter of
the blood : and when this imbibition happens during life, or soon after
death, it is important, as implying a cachectic, ill-maintained condition
of the blood, in which conditions the coloring-matter of the corpusclee
becomes unnaturally soluble. Thus blood-stained efiusions are among
the evil signs of the products of inflammation during typhus, and other
low eruptive fevers, in syphilis, and in scurvy.
III. Serous efiusions, then, appear to be rare as the results of influn-
mation ; and efi'usions of blood are but accidents in its course. The chi-
ractcristic primary product of the inflammatory process is the liquid
which the elder writers named "lymph," "coagulating or coagulable
lymph,'' and which more lately has been called " exudation," or " inflam-
matory exudation."* It is, probably always, at its first exudation, a
pellucid liquid, which passes through the bloodvessels, especially the
capillaries,t of the inflamed part ; and its most characteristic general
properties are, that it is capable of spontaneously organizing itself, even
while its external circumstances remain apparently the same, and that,
thus organized, it may proceed by development to the construction of
tissues like the natural structures of the body.
The form assumed by inflammatory lymph in its primary organization
is not always the same. There are, rather, two chief forms of organiza-
tion, which, though they arc often seen mixed in the same material, are
yet so distinct as to warrant the speaking of two varieties of inflamma-
tory lymph, by the names of fibrinous and corpuscular.X
To the fibrinous variety belong, as typical examples, all the instances
in which inflammatory lymph, effused as a liquid, coagulates into the .
solid form, and yields, when the fluid is pressed from the solid part, either
an opaque-whitish, elastic substance, having the general properties of the
• It is to be regretted that we have no distinctive appellation for this substance. To call
it " lymph" is objectionable, while, already, the same word is employed for the fluid in the
lymphatic vessels, with which it is probably not identical, though they are in many respects
similar. And the term " exudation" is yet more objectionable, since it has to be employed
as well for the act of separation from the blood, as for the material separated ; or, even if
it be limited, as the Germanized " Exsudal" is, to what has oozed from the blood, still, it is
equally applicable to all the liquid products of inflammation, and not more to any one of
them than to the serum of a dropsy, or .the material separated for normal nutrition. On the
whole, in accordance with tha generally good rule of retaining an old term till a better new
one is proposed, the words "inflammatory lymph" appear least improper.
t Or, perhaps, only from them : see a remarkable case by Mr. Bowman ; Lectures on the
Eye, p. 44.
J Corresponding varieties are distinguished or implied by Vogel, p. 30, Dr. Andrew Clark
(Medical Gazette, vol. xlii. p. 2 SO), and others.
LTMPH. 217
fibrine of the clot of blood, or the softer, and, as it is supposed, the less
perfect or less developed, fibrine of the chyle or the absorbed lymph.
Such examples of nearly pure fibrinous inflammatory lymph are
found, in the cases already referred to, among what have been supposed
to be effusions of mere serum. Such are many instances of effusions
produced by blisters and other local irritations of the skin in healthy
mm: such, too, are most of the effusions in acute inflammations of
serous membranes, especially in those of traumatic origin, ttnd in those
that occur in vigorous men. If, in any of these cases, the lymph be exa-
mined after coagulation, or, possibly, deposit in the solid form, it may
be hard to distinguish it from the fibrine of the clot of blood. The
layers of fibrinous lymph thus formed may be known to the naked eye,
when on serous membranes, by their peculiar elasticity and toughness,
their compact and often laminated structure, their grayish or yellowish-
white and semitransparent aspect, and their close adhesion to the mem-
brane, even before they have become vascular.
In the corpuscular variety of inflammatory lymph, no coagulation, in
the ordinary sense of the word, takes place ; but corpuscles form and
float free in the liquid part. Typical examples of this variety are found
in the early-formed contents of the vesicles of herpes, eczema, and vac-
cinia ; in the fluid of blisters raised in cachectic patients ; in some in-
stances of pneumonia; and in some forms of inflammation of serous
membrane.
The lymph- or exudation-corpuscles or cells, found in such lymph as
this, present numerous varieties in their several developments and dege-
nerations; but, in their first appearance, resemble very nearly the
primordial condition of the corpuscles of chyle and absorbed lymph, the
white corpuscles of the blood, and those of granulations.*
The first discernible organic form in the lymph of herpes, for example,
is that of a mass of soft, colorless, or grayish-white substance, about
s^^o^th of an inch in diameter, round or oval, pellucid, but appearing, as
if through irregularities of its surface, dimly nebulous or wrinkled. It
does not look granular, nor is it formed by an aggregation of granules ;
nor, in its earliest state, can any cell-wall be clearly demonstrated, or
any nucleus, on adding water. But, in a few hours, as the development
of this cell-germ proceeds, a pellucid membrane appears to form as a
cell-wall over its whole surface ; and now, when water is added, it pene-
trates this membrane, raising up part of it like a clear vesicle, while upon
the other part the mass retreats, or subsides, and appears more nebulous
• I have already (p. 184) referred to this fact of a single primordial form existing in tlie
mdimentB of many stnictares, which in later periods of their existence are widely different
It is a repetition of a fact in the first development of beings. In the early embryo, the
most various ultimate forms are developed from a nearly uniform mass of primordial
embryo- or germ-cells. And so it is in later life ; many of both the normal and the morbid
itnictures start from one primordial form, and, thence proceeding, diverge more and more
widely in attaining their several perfect shapes.
218 PRODUCTS OF INFLAMMATION:
or gramous than before. In yet another state, which appears to be a
later stage of development, the action of water not only raises up a oeil-
wall, bnt breaks up and disperses the outer part of the contents of the
cell, and exposes in the interior a nucleus, which is commonly round,
clearly defined, pellucid, and attached to the cell-wall.
From the various developments of these cells are derived, in the pro*
ducts of inflammation, all the several forms of corpuscles that are
described as plastic cells, fibro-cells, caudate or fibro-plastic cells, and
some forms of filaments. These correspond with the development of
granulation-cells already described (p. 127). On the other hand, from
their various degenerations descend those known as pus-corpuscles,
granule-cells, granule-masses, inflammatory globules, and much of ih$
molecular and debris-like matter that makes inflammatory effusions turbid.
The examples of inflammatory lymph which I have quoted are such ts
may be considered typical of the two varietiea: the first, in which, span-
taneously coagulating, it presents fibrine, either alone or mingled with
very few corpuscles ; and the second, in which corpuscles are found alone,
or with only a few flakes of fibrine. But, in a large number of examples
of inflammatory lymph, the fibrine and the corpuscles occur together,
mixed in various proportions, the one or the other preponderating. Sacb
instances of mixed lymph are found in the fluid of blisters in all persons
not in full health ; in all but the freshest inflammations of serous mem-
branes ; in most of the inflammatory deposits in cellular tissue, and in
most of the viscera ; and in the false membranes of croup and other
similar inflammations of mucous membranes.
Now, in general, and in the first instance, the proportions of fibrine
and of corpuscles that are present in the lymph of an inflammation, will
determine the probability of its being organized, or of its degenerating.
The larger the proportion of fibrine in any specimen of inflammatory
lymph (provided it be healthy fibrine), the greater is the probability of
its being organized into tissue ; such as that of adhesions, indurations,
and the like. On the other hand, supposing the other conditions for
development or degeneration to be the same, the larger the proportion
of corpuscles in lymph, the greater is the probability of suppuration or
some other degenerative process, and the more tardy is any process of
development into tissue. In other words, the preponderance of fibrine
in the lymph is generally characteristic of the " adhesive inflammation ;"
the preponderance of corpuscles, or their sole existence, in the liquid, iB
a general feature of the " suppurative inflammation."*
* In this view, the fibrinous and tlie corpuscular varieties of lymph nearly correspond
witli those which Dr. Williams, in his Principles of Medicine, and others, have named
plastic and aplastic; but they do not completely do so. In diOercnt instances of both
varieties, very diverse degrees of plastic property may be found; and the occurrence of
development or degeneration depends on many things besides the primary cliaractert of
lymph. They more nearly correspond with what Rokitansky (Pathologische Anatomiet
i. 90) has distinguished as fibrinous and croupous ; the varieties which be names croupooi
LTMPH. 219
The knowledge of this fact may help us to learn the several conditions
on which, in the first instance, depend these two forms of inflammation,
the contrast between which has lost none of its importance since the
time of Hunter. I will therefore at once enter on this question : — ^what
ire the conditions that determine the production of one or the other
fwiety of lymph ; the fibrinous, which, apt for development, is as the
symbol of the adhesive inflammation, or the corpuscular, which, prone to
degenerate, may be that of the suppurative inflammation ?
The conditions which are chiefly powerful in determining the character
and tendency of inflammatory lymph, are three ; namely —
1. The state of the blood ;
2. The seat of the inflammation ;
8. The degree of the inflammation.
¥mtj in regard to the influence of the state of the blood in deter-
nming the characters of an inflammatory product, Rokitansky has
Ittl^ily expressed it by saying that '^ the product of the inflammation
existB, at least in part, in its germ preformed in the whole blood.'*
Some, indeed, have supposed that lymph is only the liquor sanguinis
ended in excess through the walls of the bloodvessels; but of this
opinion we cannot be sure ; and many facts, such as the occurrence of
mflammatory lymph which does not spontaneously coagulate, «. ^., in
herpes, wiU not agree with it. Still, it is not difficult to show that a
certain character is commonly impressed by the state of the blood on the
mflammatory product from it.
I will not refer here to the cases of inoculable diseases, in which some
of the morbid material that was in the blood may be incorporated with
the product of a local inflammation, though in these the correspondence
of the blood and the inflammatory product is manifest enough ; but I
will refer to cases that may show a more general correspondence between
the two, a correspondence such that, according to the state of the blood,
so is the lymph more fibrinous or corpuscular ; more characteristic of the
adhesive^ or of the suppurative inflammation.
Some of the best evidence for this is supplied by Rokitansky, in the
Srst volume of his Pathological Anatomy ; a work that I cannot again
I, fif mud y, representing the several grades of lymph in which the corpuscles gradually
predominate more and more over the fibrine, and assume more of the characters of the
[ms-oelL I would have used his terms, but that, in this country, we have been in the habit
yt considering croupous exudations to be peculiarly fibrinous.
I defcribed the healing of subcutaneous wounds as usually accomplished by a fibrinous
aHUerial, and that of open wounds by cells developing into fibres (p. 125). These materials
Bzaetly correspond in appearance and modes of development with the fibrinous and cor-
pttaenlar varieties of inflammatory lymph. And what was then said of the liability of the
wits formed in the repair of open wounds to be arrested in tlieir development, or to degene-
rate into pus-ceils and lower forms, and of the consequent insecurity of this mode of repair
u compared with the* subcutaneous, is confirmed by the corresponding history of the two
fvieties of lymph.
220 PRODUCTS OF inflammatiok:
mention without a tribute of respect and admiration for its author, since
in it, more than in any other of his writings, he has proved himself the
first among all pathologists, in knowledge at once profound, minute, and
accurate, in power of comprehending the vastest catalogue of single
facts, and in clear discernment of their relations to one another, and to
the great principles on which he founds his systems. In this work, he
has shown clearly, that the characters of inflammatory deposits, in
different diatheses, correspond very generally and closely with those of
the coagula found in the heart and pulmonary vessels ; and that, in
general, the characters of inflammatory lymph, formed during life, are
imitated by those of clots found in the body after death, when the
fibrine of the blood may coagulate very slowly, and in contact with
organic substances.
Other evidence may be obtained by examining the products of similar
inflammations excited in several persons, in whom the state of the blood
may be considered dissimilar. And here, the evidence may be more
pointed than in the former case ; for, if it should appear that the same
tissue, inflamed by the same stimulus, will, in different persons, yield
different forms of lymph, we shall have come near to certainty that the
character of the blood is that which chiefly determines the character of
an inflammation.
To test this matter, I examined carefully the materials exuded in
blisters, raised by cantharides-plasters, applied to the skin in thirty
patients in St. Bartholomew's Hospital. Doubtless, among the results
thus obtained, there might be some diversities depending on the time and
severity of the stimulus applied ; still, it seemed a fair test of the ques-
tion in view, and the general result proved it to be so. For, although
the differences in the general aspects of these materials were slight, yet
there were great differences in the microscopic characters ; and these
differences so far corresponded with the nature of the disease, or of the
patient's general health, that, at last, I could generally guess accurately,
from an examination of the fluid in the blister, what was the general
character of the disease with which the patient suffered. Thus, in cases
of purely local disease, in patients otherwise sound, the lymph thus
obtained formed an almost immixed coagulum, in which, when the fluid
was pressed out, the fibrine was firm, elastic, and apparently filamentous.
In cases at the opposite end of the scale, such as those of advanced
phthisis, a minimum of fibrine was concealed by the crowds of corpuscles
imbedded in it. Between these were numerous intermediate conditions
which it is not necessary now to particularise. It may suffice to say
that, after some practice, one might form a fair opinion of the degree in
which a patient was cachectic, and of the degree in which an inflammation
in him would tend to the adhesive or the suppurative character, by these
exudations. The highest health is marked by an exudation containing
the most perfect and unmixed fibrine ; the lowest, by the formation of
LTMPH. • 221
the most abundant corpuscles, and their nearest approach, even in their
early state, to the characters of pus-cells. The degrees of deviation
firom general health are marked, either by increasing abundance of the
emrpusdes, their gradual predominance over the fibrine, and their gradual
approach to the characters of pus-cells : or, else, by the gradual deterio-
ration of fibrine, in which, from being tough, elastic, clear, uniform, and
of filamentous appearance or filamentous structure, it becomes less and
less filamentous, toiler, more paste-like, turbid, nebulous, dotted, and
mingled -with minute oil-molecules.
I would not make too much of these observations. They are not
enough to prove more than the rough truth, that the products of similar
inflammations, exdted in the same tissue, and by the same stimulus, may
be in different persons very different, varying especially in accordance
vith the several conditions of the blood. Yet, simple as the observa-
tions are, they may illustrate what often seems so mysterious ; namely,
the different issues of severe injuries inflicted on different persons. To
what, more than to the previous or some acquired condition of the blood,
can we ascribe, in general, the various consequences that follow the same
operations on different patients ? The local stimulus, and the conditions
by which the inflammatory product finds itself surrounded, may be in all
alike ; but, as in the simpler case of the blister, the final events of the
inflammation are according to the blood.
I cannot doubt that a yet closer correspondence between the blood,
and the products of inflammation derived from it, would be found in a
aeries of more complete observations ; in such, for instance, that the
characters of the blood drawn during life, or, much better, of the clots
taken from the heart after death, might, in a large number of patients,
be compared with those of inflammatory exudations produced, as in the
cases I have referred to, by the same stimulus applied to the same tissue.
In the few cases in which I have been able to make such examinations,
this view has been established ; and it is confirmed by the parallelism
between the varieties of lymph that may be found in blisters, and the
varieties of the fibrinous coagula in the heart described by Rokitansky."*"
The varieties of solidified fibrine which he classes as fibrines 1, 2, 3, 4,
are very nearly parallel with what I have enumerated as the stages from
the best fibrinous to the corpuscular lymph ; and, as I have already
implied, he regards these clots found in the heart and vessels as repre-
senting the different ^'fibrinous erases" or diatheses of the blood.
I mentioned, as the second condition determining the character of
inflammatory lymph, the seat or tissue which the inflammation occupies.
I need hardly remind you that, since the time of Bichat, there has
been a general impression that each tissue has its proper mode and pro-
* Pathologiacbe Anatomie, B. i. p. 143.
222 • PRODUCTS OF inflammatiok:
duct of inflammation. The doctrines of Bichat on this point vere^
indeed, only the same as Mr. Hunter held more conditionally, ta^
therefore, more truly ; but they gained undisputed sway, among the
principles of that pathology which rested on general anatomy as iti
foundation.
The facts on which it is held that, in general, each part or tissue is
prone to the production of one certain form of inflammatory exadation,
are such as these : that, e. g, in the apparently spontaneous mflamma-
tions of the skin, lymph with corpuscles alone is produced, as in heipea,
eczema, erysipelas ; that in serous membranes, the lymph is commonly
fibrinous, and has a great tendency to be organized, and form adhesioDB;
that in mucous membranes there is as great a tendency to suppuration;
that in the lungs, both fibrine and corpuscles are abundant in the lymph,
and the corpuscles have a remarkable tendency to degenerate into either
pus-cells or granule-cells ; that in the brain and spinal cord the tendencj
is to the production of a preponderance of corpuscles, that quickly
degenerate into granule-cells ; while in the cellular tissue, both fibrine
and corpuscles appear, on the whole, equally apt to degenerate into pai^
or to be developed into filamentous tissue.
Now these are, doubtless, facts ; but the rules that it ia sought to
establish from them are not without numerous exceptions. The ifr>
stances I have lately quoted show that, in one tissue at least, the ddn,
the products of inflammation will vary according to the condition of the
blood, although the inflammation be always similarly excited by the same
stimulus. So, too (as Mr. Hunter remarks'*"), if it were the tissue alone
that determines the character of an inflammation, we ought to hive
many forms of inflammation in the same stump after amputation:
whereas, all is consistent ; or the difierences among the tissues are only
differences of degree ; they all adhere, or all granulate and suppurate,
or all alike inflame and slough.
It is therefore not unconditionally true that each tissue has its proper
mode and product of inflammation. It has been too much overlooked
that a morbid condition of the blood, or perhaps of the nervous force,
may determine, at once, the seat of a local inflammation, and the fom
or kind of inflammatory product. Thus, e, g. the variolous condition of
the blood may be said to determine, at once, an inflammation of the
skin, and the suppurative form of inflammation ; for, in variola, whatever
and wherever inflammations arise, they have a suppurative tendency.
So, in rheumatism, whether it be seated in muscles, ligaments, or synovial
membranes, in serous membranes, or in fibrous tissues, there appears the
same tendency to serous and fibrinous effusions, which are slow to coagu-
late or organize, and even loss prone to suppuration. The same might
be said of the local inflammations that are characteristic of typhus and of
• Works, vol. iii. p. 313.
LTMPH. 228
gout, «nd, I beUeve, of all those diseases in which a morbid condition of the
Uood numifests itself in some special local error of nutrition. And all
these cases are illnstratiYe of the general truth, that each morbid condi-
tion of the hlodSi is prone both to produce an inflanmiation in a certain
part, and to give to that inflammation a certain form or character.
CSases, however, remain, that prove some influence of the tissue in
determining the product of its inflammation ; in determining, I mean,
the primary form, as well as the later development, of the product :
and the true influence of the tissue in this respect is best shown in some
of the cases in which the inflammation, excited, apparently, by the same
means, has happened coincidentally in two or more very difierent parts
in the same person. Thus we may find, e. g, that, in pleuro-pneumonia,
the lymph on the pleura is commonly more fibrinous than that within the
aabstance of the lung ; and adhesions may be forming in the one, while
the other is suppurating. In cases of coincident pneumonia and peri-
carditis, the lymph in the lung may appear nearly all corpuscular, and
iQ the corpuscles may show a tendency to degenerate into granule-cells,
vhfle the lymph on the pericardium may have a preponderance of fibrine,
and what corpuscles it has may tend to degenerate into pus-cells. So,
too, one may find, in the substance of an inflamed synovial membrane,
ibnndant lymph-cells, while all the exudation on its surface may appear
pnrQlent.
I have said that the fluid of the sac in cases of strangulated hernia
eoagiulates on withdrawal from the body : it may be regarded as a mixture
of serum and fibrinous lymph from the inflamed serous membrane. But,
in a case in which I was able to examine a pellucid fluid contained in
large quantity in the cavity of the strangulated intestine, and which
ippeared to be the nearly pure product of inflammation of the mucous
membrane, there was no fibrine; the fluid was albuminous, and contained
abundant lymph-cells.
Other instances of this might be mentioned. These, however, may
seem enough to establish the influence of the second condition that I
mentioned; namely, the seat of an inflammation, as determining the
daraeter of its products.
The third condition on which the character of the lymph chiefly
depends is, the degree of the inflammation producing it.
The influence of a tissue, in determining the character of the lymph
formed in its inflammations, may be in some measure explained, by
believing that the primary product of inflammation is, often, a mixture
of lymph, and of the secretion, or other product, of the inflamed part,
more or less altered by the circumstances of the inflammation.
When it is seen that in inflammations of bone the lymph usually ossi-
ies ; in those of ligament, is converted into a tough ligamentous tissue ;
and that, in general, lymph is organized into a tissue more or less cor-
224 PRODUCTS OF inflammation:
responding with that from whose vessels it was derived ; it is usuallj
concluded that this happens under what is called the assimilative in-
fluence of the tissues adjacent to the organized lymph. But we maj
better explain the facts, by believing that the material^ formed in iht
inflammation of each part partakes, from the first, in the properties of
the natural products of that part ; in properties which, we know, oftea
determine the mode of formation independently of any assimilatiTe
force (p. 52).
We have some evidence of this in the products of inflammation of
secreting organs, the only structures of which we can well examine the
natural products in their primary condition. In a moderate amount of
inflammation of a secreting gland, the discharge is usually a mixtuie
of the proper secretion in a more or less morbid state, and of the
inflammatory product. Thus we find morbid urine mixed with fibrine,
or albumen, or pus. In cases of inflamed mucous membranes, the pro-
duct is often a substance with characters intermediate between those
of the proper mucous secretion and those of lymph. Or again, in serooB
membranes, we may perceive a relation between their natural secretiOD
and the usual products of their inflammation.
Now, these considerations are equally illustrative of the influence of
the third among the conditions enumerated as determining the character
and tendency of inflammatoiy products ; namely, the degree or severitj
of the disease. For, as a general rule, the less the degree of inflamma-
tion is, the more is the product like that naturally formed in or by the
part, till we descend to the border at which inflammation merges into
an exaggerated normal process of secretion: as in hydrops artieoli,
hydrocele, coryza, &c.
These, it may be said, arc only instances of secretions. But the
instances of the so-called inflammatory hypertrophies may be regarded u
parallel with those just referred to ; for the analogies between secretion
and nutrition are so numerous, the parallel between them is so close,
that what can be shown of one may be very confidently assumed of the
other. We may therefore believe, that in the inflammation of any part,
the product will, from the first, have a measure of the particular pro-
perties of the material employed in the normal nutrition of the part:
that, as in the inflammation of a secreting organ, some of the secretion
may be mingled with the product of the inflammation, so in that of any
other part, some of the natural plasma, i. e. some of the natural mate-
rial that would be effused for the healthy nutrition of the part, may he
mingled with the lymph. The measure of likeness to the natural struc-
ture acquired by the inflammatory product in its development, will thus
bear an inverse proportion to the severity of the inflammation ; because,
the more the conditions of nutrition deviate from what is normal, the
more will the material effused from the vessels deviate from the normil
type. In severest cases of inflamlnation we may believe that unmixed
MUCUS. 225
lymph is produced, the conditions of the due nutrition of the part being
irholly changed ; but when the inflammation is not altogether dominant,
its product will be not wholly contrary to the natural one, and will, from
the first, tend to manifest in its development some characters corre-
qwndent with those of the natural formations in the part. Thence,
mwards, this correspondence will increase as the new tissue is itself
mrarished : as scars improve, so do false membranes and the like become
more and more sinular to natural tissues.
To sum up, then, what may be concluded respecting the conditions
that, in the first instance, may determine the adhesive or suppurative
characters of an inflammatory exudation : they arc, 1st. The state of
the blood — ^its diathesis or crasis — ^the power of which is evident in that
the same material may be exuded in many inflamed parts in the same
person ; in that this material may exhibit peculiar characters correspondent
irith those of the blood itself; and in that, in different persons, an in-
flammation excited in the same tissue, and by the same stimulus, will
produce different forms of lymph, corresponding with the differences of
die blood. 2d. The seat of inflammation, and the tissue or organ af-
fected ; of which the influence is shown by cases in which, with the same
condition of blood, different forms of lymph are produced in different
parts or organs. 3d. The severity, and acute or chronic character, of
the inflammatory process, according to which the product deviates more
mr less from the character of the natural secretion or blastematous effu-
non in the part.
The primitive character or tendency of any case of inflammation
might be represented as the resultant of three forces issuing from these
conditions.
The last product of inflammation of which I have to speak, is Mucus.
Peculiar difficulties, owing to imperfect investigations of what normal
mucus really is, beset this portion of our subject.
Normal mucus, so far as it has been examined, is a peculiar, viscid, ropy,
pellaeid substance, which, of its own composition, has no corpuscles or
organized particles. Such mucus is to be found in the nasal cavities of
sheep and most large mammalia, and in the gall-bladder when its duct
has been totally obstructed. In these parts, mucus may be found with-
out corpuscles ; and probably there are other examples of such pure and
mimixed mucus.
With all these, however, accidental mixtures commonly occur, of epi-
thelial particles from the mucous membrane, and of corpuscles from the
imbedded mucous follicles. And these particles vary according to the
Seat of the membrane, the fluid with which the mucus may be mixed, as
gastric acid, intestinal alkali, &c., the time the mucus may lie before dis-
charge, and other such conditions.
The first effect of a stimulation, within the normal limits, is to increase
15
226 PRODUCTS OF INFIiAMMATIOK.
the secretion of the proper mucus, making it also more liquid ; to increase
the quantity of the epithelium cast off mth the liquid ; and, often, to
induce the premature desquamation of the epithelium, fio that particles
of it imperfectly formed may be found in the mucus. Many of these
immature epithelial particles have been named mucus-corpuscles or mucus-
cells.
In an established inflammation of a mucous membrane, there appear,
mixed with mucus, and with imperfect or degenerate epitheUum, mate-
rials which closely resemble, if they are not identical with, the lympb-
products of inflammation in other parts. I am, indeed, disposed to think
that we should not draw a strong contrast between the inflammatory pro-
ducts of mucous membranes and those of serous membranes, and other
parts, except in relation to the material, with which, in the several cases,
they are mixed. For, in certain inflammations of mucous membranes,
we find fibrinous exudations ; as in Hunter's experiment of injeetiiig
strong irritants into the vagina of asses ;* they are found also, but lea
pure, in croup and bronchial polypus ;t and I have seen them in Ae
renal pelvis, ureters, and bladder in a ca^e of calculus. In other cases,
we find, either without fibrine, or mixed with minute soft flakes of it,
corpuscles, which are, also, commonly called mucus-corpuscles, but whidi
appear to differ from those in the lymph already described, only becaiM
of the peculiarly viscid fluid in which they lie. All appear to be, alike^
lymph-corpuscles : but in the one case they lie in a serous, in the othei^
in a mucous fluid, in which they appear clearer, more glistening, mm
perfectly pellucid, less plump, and are less acted on by water.
From these inflammatory products in mucus may be derived, by variou
degenerations of the fibrine, the flaky and molecular materials which
commonly make morbid mucus look turbid and opaque ; and by cone-
spending degenerations of the corpuscles (i. e. of the lymph-corpuscles,
not of any normal cells or nuclei), the more frequent pus-cells, whiA
make the transition to the complete pus formed on mucous membranes
in active inflammation.
Such degenerations are more frequent in the products of inflamed
mucous surfaces than are any forms of development. Development of
fibrine, I suppose, never happens here ; but in the corpuscles some indi-
cations of it may be found, especially when the inflammation is voj
slight, as in the end of a bronchitis. In this case, among the corpuscles,
many may be found enlarged, having distinct cell-walls, and clear, well-
defined nuclei with nucleolL
But among these there are usually many that present a peculiar
pigmental degeneration. In the gray, smoke-colored mucus, commonlj
expectorated at the close of bronchitis, the peculiar color, though
commonly ascribed to the mixture of inhaled carbon, is due to the
• Works, vol. iii. p. 341. Museum of the College, Nos. 83, 84.
t See Henle, in his Zeitschrift, t ii. p. 178.
BBYELOPMBNTS OF LTMPH. 227
abundance of cells containing more or less numerous black pigment-
granules. Particles of carbon or soot may by chance be present, but
fig. 88.
they only trivially contribute to the color : it depends on the number of
these pigment-ceUs, to which it is easy to trace the transitions from the
lymph- or mucus-corpuscles. The chief stages of transition are seen in that
die cells enlarge to a diameter of about jf^y^th of an inch, become
dearer, and acquire one or two clear oval nuclei ; but, at the same time,
minute black granules, almost like those of melanotic cells, accumulate
m them ; and these, increasing in number and clustering, may at length
fill the whole cell, while the nucleus disappears. Subsequently, the cell-
waU may burst or dissolve, and the black granules be set free.
It can hardly be supposed that the black granules are in any way
derived from inhaled carbon, although it seems that this kind of mucus
is most abundant in those who are exposed to atmospheres laden with
eoal-amoke; for the color is completely destroyed by immersing the
mocuB in nitric acid or solution of chlorine. The occurrence of such
pigment-cells being, I believe, peculiar to the mucus of the air-passages,
may be connected with the general tendency of inflammatory products
to imitate the properties of the natural products of the inflamed part ;
for they closely resemble the black pigment-cells from which the lungs
and bronchial glands derive their black spots and streaks and other
marks. And it may be added, that their peculiar abundance in the
slightest forms of bronchitis, compared with their absence in acute cases,
affords another example, that the likeness of the morbid to the natural
product is inversely proportionate to the severity of the inflammation.
LECTURE XV.
DEYBLOPMBNTS OF LTMPH.
In the last lecture I considered part of the contrast between the pro-
cesses of nutrition in the normal and in the inflammatory state, endea-
voring to illustrate the nature of the materials exuded from the blood-
vessels of inflamed parts. The contrast in this particular cannot,
228 DEVELOPMENTS OF LTMPH.
indeed, be accurately drawn : for we have, as yet, no certain knowledge
of either the properties or the quantity of the material separated from
the blood, for the ordinary nutrition of each part ; we have no normal
standard wherewith to compare, in this respect, the processes of disease.
It is evident that the exudation in an inflamed part is superabundant;
but its error in quality can be proved only by its diversity in varioufl
cases, and by the differences which it commonly presents in die rate and
method of its development or degeneration. It is of these processes in
the exuded lymph, and of the contrast between them and the normal
maintenance of a part, that I propose next to speak.
The biography of the lymph-product comprises much of the most
important part of the pathology of inflammation : and if it were required
to point out what, since Hunter's time, has contributed most to the pro-
gress of general pathology, one could scarcely hesitate to name the full
appreciation of the fact, that inflammatory lymph, and other primaij
products of disease, have an independent life, and are, of their own
nature, capable of appropriate development, degeneration, and disease.
We may regard this as one of the best achievements of the observationi
which Schleiden and Schwann began to generalize ; for, till it was cleaily
apprehended, the idea of a part being organizable meant scarcely more
than it admitted of being organized by the forces of the parts around it;
that it could be built up by the arteries, and modelled by the absorbents,
as a material plastic, yet passive, in the hands of workmen. Hence was
derived the erroneous direction of inquiries, which sought for bloodvessels
as the essential characters of organic life in a part ; and for their varie-
ties of size, and number, and arrangement, as the measures of the ability
and method of development.
Now, more truly, we may study the lymph, as having a life only so
dependent on the blood and vessels as are all the tissues of the body —
dependent on them as conditions of life, but not as sole arbiters of the
method or direction of the vital transformations. And I venture to
think, that the chief aim of our observations, in this part of the pathology
of inflammation, should be to learn, now, the exact relation in which the
several products of inflammation stand to certain primary forms, as deve-
lopments or degenerations from them. The catalogue of various cor-
puscles is already swollen to an extent that is confusing to those who
arc familiar with them, and repulsive to those who would begin to study
them. It would be an easy task to increase it, and it might have a seem-
ing of accuracy to do so ; but what we want, is such a history of the
inflammatory lymph, that we may arrange the components of this cata-
logue as indicating so many progressive stages of development, degene-
ration, or disease, in the primary products of inflammation. An attempt
to construct such a history is the more advisable, for the sake of the
illustration which it may afford to the history of normal structures.
There are, as I have already said, no normal instances in which we can
LYMPH. 229
see the materials that are cifused for the nutrition of parts ; but we may
iflsnme something concerning them and their progressive changes from
the analogy of the materials that are more abundantly produced in
inflammations.
I propose, then, to devote the present lecture to some general, and
only a very general, account of the development of lymph. But let me
first state the sense in which the term development is here to be employed.
I have said (p. 19 and 77) that, in the generally accepted meaning of
development, we have adopted an arbitrary standard of comparison, in
the assmnption that the nearest approach to organic perfection is in the
human body, at the age of manhood. The assumption may be right on
the whole ; and a less arbitrary definition of development would, proba-
bly, be less useful ; yet it may be observed, that in what we take for the
period and standard of perfection, many parts that were once highly
organized and active have passed away, as the thymus gland ; and some
are, in certain respects, rather degenerated than developed, as the renal
capsules and the bones. Development, in its highest sense, should imply
not merely that a part becomes more fit for membership under the most
perfect economy, but, also, that such fitness is acquired with greater
complexity of chemical composition, or with greater evidence of formative
or other organic power, or with greater difference from the structure or
composition of lower beings. With none of these characters of develop-
ment does such a process as that of ossification agree ; and, therefore, as
I have said before, when we call it the development of bone from carti-
lage, it should be with the understanding that the term is applicable only
because bone is the proper material of the skeleton of the adult human
body.
This distinction is important in the pathology of inflammation. In
til true or complete development we may believe there is a larger ex-
penditure of vital force than in any other organic act ; for all such de-
velopment, too, the external conditions need to be the most complete,
and the least interfered with ; such development is the highest achieve-
ment of the formative force, the highest instance of what might be
understood as ''increased action" in a part.
To speak, therefore, of the development of inflammatory products,
when already the normal development of the body is completed, may
seem to imply the exercise of unusual vital force ; the renewal, as it
were, of the pristine embryonic vigor ; and the existence of conditions
more favorable for nutrition than even those of health are. But we may
be led to judge differently, if it should appear that most or all of the
so-called developments of inflammatory products are instances in which
the tissues, though they are formed into the likeness of such as exist in
the perfect human frame, yet acquire characters of lower organization
than those they had in their earliest state. It will appear that they are
280 BBVELOPMBNTS OF LTMPH:
such ; and that however much the inflammatorj products may become,
by their changes, better suited for the general purposes of the economy,
they are, in relation to their own condition, rather degenerated than
developed. The changes that they undergo are, therefore, not alwajB
declaratory of a large expenditure of vital force ; they are not such u
the term " sthenic," or " increased action," applied to the inflammatoij
process, would suggest ; not such as to imply that it is an exaggeration
of any normal method of nutrition.
With this understanding, however, the changes I shall presently de-
scribe may be called developments of inflammatory lymph or exudation;
they are developments in the sense of being approximations to the like-
ness of the natural tissues of the adult human body.
In the last lecture I spoke, generally, of the conditions upon which
depends the production of such inflanunatory lymph as may be most apt
for development. They are all such as favor the production of a lymph
rich in fibrine, and that fibrine clear, homogeneous, elastic, tough, and
filamentous. But even such lymph as this may altogether fail to be de-
veloped, or may be arrested in any stage of its development, and turned
into the downward course of degeneration, unless favorable external con-
ditions arc present with it. For the development of lymph, of whatever
form, nearly all those conditions are requisite which are necessary fbr
the normal development of the proper constituents of the body. It
needs, in general, the due supply of healthy and appropriate blood, the
normal influence of the nervous force, and, for the highest and latest
forms of development, the normal condition of the proper elements of
the affected part.
Now, the existence of these conditions for the development of lymph
implies a cessation of the inflammatory process, and a recovery from
whatever originated or maintained the inflammation. So long as inflam-
mation lasts, no high development of the exudation already formed will
take place ; rather, fresh lymph will be continually exuded, hindering
the due process of development, and hindering it the more, because, as
the general health suffers through the continuance of the disease, so the
lymph freshly formed will be less and less prone to organization. We
may see this illustrated in bad cases of pleurisy. The layers of lymph
next to the pleura are always more prone to organization than the later-
formed layers that lie next the cavity ; while within the cavity all the
lymph may retain its fluid form, or may have degenerated into pus. So,
more openly, we may see an illustration of the ill effects of abiding in-
flammation, in the healing of wounds by granulation. An inflammation,
ensuing or continuing in the wound^ hinders all development of granula-
tion-cells, even though it may be too slight to hinder their formation, and
may be favorable to the production of the ichor- and pus-cells. We may
truly say, that the conditions most favorable to the abundant production
NS0ES8ART CONDITIONS. 281
of Ijmph are among the most unfavorable to its development, t. e. to its
complete and higher organization.
Even when the inflammation has ceased, and fresh lymph is not
formed, still, development is often prevented or retarded for want of
Bome necessary condition. The bloodvessels, long dilated, may remain
in a state of congestion, distended as if paralyised^ and filled with slowly
moving blood. In such a state of *^ passive congestion,'' so apt to follow
more acute attacks, development wUl not happen in even well-disposed
lymph. We have parallel facts in the tardy development of granulations
on the legs, in the healing of ulcers ; and how much this depends on the
defective movement of the blood is well illustrated by a specimen"*" ap-
propriate to an observation of Mr. Hunter's. It shows three ulcers of
the int^uments of a leg ; they were all granulating, and all healing ;
bat their progress in healing was inversely proportionate to the hinder-
ances of the blood. The lowest of the three, that most distant from
the heart, and of which the vessels were subject to the pressure of the
highest column of blood, was least advanced in healing ; while the up-
permost of the three was most advanced, and was nearly cicatrized.
But let us suppose all the conditions for development provided ; what
win now determine the direction or result of the process ? Into what
tissuea will ^e lymph be formed ? Two chief things will determine this :
first, the general natural tendency of organizable lymph, produced in
inflammation, is to form filamentous, i. e. fibro-cellular or fibrous tissue ;
and, secondly, all lymph has some tendency to assume, sooner or later,
the characters of the tissue in or near which it is seated, or in place of
which it is formed.
The natural tendency of lymph to th^ construction of fibro-cellular or
connective tissue, such as composes false membranes or adhesions, and
many permanent thickenings and indurations of parts, is shown by the
production of this tissue under all varieties of circumstances, and in
nearly all parts ; even in parts which, naturally, contain little or none.
Thus, it is found in the brain, and in glands, as in the testicle ; within
joints, even where adhesions only pass from one articular cartilage to
another ; in the adhesions and tldckenings of the most diverse serous
membranes ; in the thickenings of the most diverse mucous ones. And
with aU these, we have the corresponding facts in the healing of wounds.
All granulations, springing from what surface they may, tend, at least
in the first instance, to the formation of filamentous tissue, such as we
see uniting all parts in a stump ; and a large proportion of subcutaneous
injuries are repaired by similar tissue, whatever parts may have been
divided. And, sometimes, we may find incomplete instances of this
development where the lymph is not even in continuity with any tissue,
but floats free ; as in ascites, or in eflfusions into joints.
* Museum of the Collegei No. 26.
232 DEVELOPMENT OF LTMPH INTO
But besides this general tendency, we may recognise in inflammatory
lymph a disposition to assume characters belonging to the part in whidi
it was produced ; so that, for instance, that about fibrous and ligamen-
tous parts will be developed into peculiarly tough fibrous tissue ; that
about bone will become osseous ; that in the neighborhood of epithelinm
will form for itself an epithelial covering ; and so on. I referred to this
fact in the last lecture, and suggested that this tendency of the developed
lymph, to conform to the characters of the parts around it, is probably
due to the original and inherent quality of the lymph ; that the material
formed in the inflammation of each part partakes, from the first, in the
properties of the natural products of that part, and partakes of them in
an inverse proportion to the severity of the inflammation ; because, the
more the normal conditions of nutrition are deviated from, the more wiU
the material produced be unlike the normal product. Besides, when the
conditions are restored to the normal type, the organized product of in-
flammation will constantly approximate more and more to the characten
of the parts among which it is placed, or with which it has acquired
membership. As scars improve, u e. gain, gradually, more of the cha-
racters of skin, so do false membranes, and the like structures, foimed
by the organization of inflammatory lymph, acquire, by their own nutri-
tion and development, more nearly the characters of the parts with whidi
they are connected. Thus false membranes in the serous cavities acquire
a covering of epithelium exactly like that which covers the original
serous membrane, and their tissue becomes perfectly fibro-ccllular ; ad-
hesions of the iris may become black, apparently from the production of
pigment-cells like those of the uvea ; thus, too, in adhesions of the pleuia^
even when they arc long and membranous, pigment may be formed as in
the pulmonary pleura itself; and thus many other inflammatory products
are gradually perfected, till we may come to doubt whether they be of
normal or of morbid origin, so complete is the return from the aberrant
action.
I will endeavor, now, to describe more particularly the transitions to
the several tissues that may be formed from inflammatory lymph. I
need not, indeed, describe the minute changes of development ; for, as
the fibrinous and corpuscular varieties of lymph resemble very nearly the
two forms of reparative material, so (as far as they are yet studied), their
respective methods of development are equally similar. On these pointSi
therefore, I may refer to former lectures (p. 126, 128, 141, 163, &c.);
and, if it seem strange that disease should thus so closely imitate health,
let it be repeated, that this process of development of the lymph is not
disease. The lymph is, indeed, produced in inflammation, but it is de-
veloped in health, when all the natural conditions of nutrition are re-
stored.
The instances arc very numerous in which the inflammatory lymph,
FIBBO-CELLULAR TISSUE. 288
fdlowing its natural tendency, becomes fibro-cellular, or fibrous, tissue.
The general forms which, in these instances, it assumes are (1) adhesions,
where the new-formed tissue is between free surfaces, and unites them ;
(2) thickenings, where the formation is in the substance of membranes ;
(8) indurations, with or without contractions, where it is in the substance
rf organs ; (4) opacities of certain parts that were transparent.
The best examples of the formation of fibro-cellular tissue from inflam-
matory lymph are in the adhesions, or false membranes, found after in-
bmmation of serous or synovial membranes. In the former, especially,
the lymph is apt, in such favorable conditions as I have specified, to be
thus developed. In an acute peritonitis, or pleuritis, for instance, it is
woally, in the first instance, deposited in layers .of uncertain thickness
an the opposed surfaces of the membrane. The condition of these lay-
en is variable. The lymph is sometimes grayish, half-translucent, com-
pact, and laminated, consisting chiefly of fibrinous material, and peculi-
arly apt for development : in other cases, it is yellowish, opaque, soft,
saocnlent, or almost creamy, having a great preponderance of corpuscles,
and being less fit for development : and between these forms are many
connecting yarieties of appearance.
In the first instance, the connexion of the lymph with the surface of
the serous membrane is, usually, such that it may be cleanly stripped off*.
Its free surface presents great varieties ; it may be flocculent, or villous,
reticular, perforated, or nearly smooth. Commonly, at first, the surfaces
of the two layers (the visceral and parietal layers as they may bo called,
after the portions of the serous membrane on which they are severally
placed) are separated by serous fluid exuded, in various quantity, with
the lymph. But they may be, in parts, continuous, or connected by
bands or columns ; and, usually, when the inflammation ceases, and such
a state of circulation is restored as is favorable to the organization of the
lymph, the same state is equally adapted to the absorption of the super-
abundant fluid. In this case, the opposed surfaces of the two layers of
lymph are gradually brought into contact with one another, and with por-
tions of lymph which had floated in the fluid : and now, as their organi-
zation proceeds, they are all united ; they become continuous, and form
^'adhesions" between the opposite surfaces of the serous membrane,
whether these be the surfaces of adjacent organs, as the abdominal vis-
cera, or of any organ and of the cavity enclosing it, as in the case of the
testicle and tunica vaginalis.
The method, and the chief part of the plan, of the organization of
lymph in these cases, are, I believe, similar to those described in the
healing of wounds by primary or by secondary adhesion ; and the gene-
ral results are the same. Various as are the forms and other conditions
of adhesions and false membranes (depending as they do on the relative
positions and mobilities of the parts that they connect), yet their struc-
ture, when complete, is, I believe, uniform. They consist of well-orga-
284 DSVBLOPMBNT OF LTMPH INTO
nized fibro-ccllular or connective tissue, with which (perhaps only at a late
period) elastic tissue may be mingled : they possess abundant bloodves*
sels, the chief of which are parallel to the direction of their filaments;
and their free surfaces are covered with an epithelium like that of the
membranes which they connect.
Fibro-cellular tissue is formed in adhesions of synovial membranes is
well as of serous membranes ; and, probably, in the same manner. In
both cases, moreover, it is very usual for lymph to be exuded in and jnst
beneath the membrane, as well as on its surface ; and this infiltrated or
interstitial lymph, becoming organized, produces thickening and opacity
of the membrane. The coincident organization of the lymph, in both
positions, is well shown in the frequent instances of white spots in the
cardiac pericardium, with adhesions between the pericardial surfaces.—
Such white spots, when completely formed, consist of new fibro-cellolir
tissue, exactly like that of the adhesions. It is by similar interstitiii
exudation of lymph, and by its development into fibro-cellular tissue, thst
the frequent adhesions take place between parts which, though connected,
should slide freely upon one another : such as adjacent tendons, &c.—
From this is derived a large share of the stifiness that remains about in-
jured joints ; the parts that should slide pliantly over them are fixed bj
the new-formed interstitial fibro-cellular tissue. So, too, are formed vari-
ous morbid thickenings of parts : as of pieces of integument, capsules of
joints, &c. But, in many of these cases, the lymph retains very long its
rudimental structures, and is, perhaps, on this account, peculiarly apt to
degenerate and permit absorption or the ulcerative process. I know no
better example, for microscopic examination of interstitially deposited
lymph, than an indurated chancre : but I have never found one in which
the lymph-cells had reached a further development than the elongated
caudate form.
Fibrous Tissue, as the result of the development of lymph, is found
when the exudation is interstitial in any fibrous tissue : as in ligaments,
capsules of joints, and the like. The best examples of it are in the
laminated nodular thickenings of the capsule of the spleen, or the
thickening and induration of the periosteum, or the capsule of the hip-
joint in chronic rheumatic arthritis. In all these cases, the new material
is derived from repeated, but not acute, inflammations ; therefore, pro-
bably, though excessive, it is not widely difierent from the normal
material for nutrition: and, the conditions for nutrition being little
disturbed, it is developed into the exact likeness of the original texture
with which it is intermingled and confused.
As the fibro-cellular and fibrous tissues, formed from inflammatory
lymph, become more perfectly organized, they are prone to contract :
imitating the contraction already described in granulations and scars
(p. 159). Hence, in part, the contraction of the wall of the chest after
BONB. 285
r, ftnd the yarioiis diBplacementB and deformitieB of organs that
become adherent to adjacent parts : hence, in part also, the con-
feieCiona of inflamed organs, as of the liver in cirrhosis : hence, too, an
en to the rigidity of joints when the parts around them have been
td ; and hence, with yet greater mischief, the contractions of the
led valves and tendinous cords of the heart.
Adiposx Tissue may be formed, if not directly from inflammatory
•tymphy yet in the fibro-cellular tissue of completely organized adhesions.
: I think it is not often so formed: but, lately. Dr. Elirkes foimd a lung
! flf which all the anterior part was covered with well-organized false
I membrane ; and in part of this was a quantity of perfect adipose tissue,
i. sore than four ounces in weight
Elastic Tissue is sometimes abundantly formed in the adhesions
defdoped from inflammatory lymph. I have not seen it except in such
■■ are completely organized : and I think it is, in this case, as in the
fonnation of scars, a late production (see p. 129 and 159). I believe,
abo, with Virchow,* that its formation depends, in some measure, on the
Bonbrane that is inflamed ; pleural adhesions being most favorable to
it In these it is often abundant; its principal, but always slender,
flaments lying in the same general direction as those of the fibro-
edhdar tissue.
Epithblium I have already mentioned as covering the surfaces of
wdtformed adhesions. I know of no observations proving whether the
cptkelial cells are developed directly from the lymph, or are a later
coDstmction from materials derived from the blood of the adhesion's
Ycnels : but it is not rare to find, in inflammation of serous membranes,
reemt lymph-cells presenting many characters indicative of development
towards epithelium ; flattened and enlarged, and having circular or oval
deir nuclei.
Bora 18 often formed from inflammatory lymph. It may appear as a
lite transformation of lymph that has been organized into perfect fibrous
tiflrae; as in the osseous plates that are sometimes found in the false
membranes of the pleura, or in the pericardium. In most of these, how-
ever, there is not true bone, but an amorphous deposit of earthy matter,
whidi is imbedded in the fibrous tissue, or which (as Bokitansky holds)
is tbe residue of the degenerated and partially absorbed tissue.
The proper condition for the transformation of lymph into bone is
tiiat in which the exudation takes place in an inflammation seated in the
* VeriiuMll. der Phyt.-Med. Geselltchaft in WOnburg, 1850, p. 142. He describes hero
* pcmikr thornjr or dentate structure often presented by tbe elastic filamenu in old adhe-
liooi
286 DEVELOPMENT OF LTMPH INTO
bone itself, or, else, in or near the periosteum. Such inflammations have
been called " ossific ;" and the Museum of the College, like every other,
abounds with specimens of their various results.
There is a great lack of minute observations respecting both Ai
characters of the lymph exuded in inflammations of bone or perio6feeimi| i
and the methods of its ossification. Such as have been made, indicafiii'
as might be expected, a close resemblance to the processes described in
the repair of fractures* (p. 162, ct seq.) The lymph produced in mode-
rate inflammation, and therefore likely to ossify, is, at first, according to
Bokitansky, a dark-red exudation, like gelatine, which, being gradually
decolorized, becomes white, and at the same time acquiring firmnea,
becomes like soft flexible cartilage, and then like ruddy succulent bone.
But though it be like cartilage, I suspect that cartilage is very rarely, if
ever, formed in inflammation of bone ; for it seems to be formed in tlie
repair of fractures only when the conditions are more favorable thin
they are likely to be in any inflammations. Probably the lymph is mow
or less developed towards the fibrous tissues when it ossifies ; and, as in
the repair of fractures, so here, we may believe that ossification may be
postponed till the fibrous tissue is quite formed, or that it may ensue in
the rudimcntal state of the tissue, whether in a nucleated blastema, or in
cells like those of granulations.
It would be hardly possible to explain, without illustrative specimens,
all the various appearances of bone new-formed in or after inflamma-
tions. It may be produced in the very substance of compact bone, after
the softening and expansion of the original tissue which occur in the
earlier parts of the inflammatory process, and to which I shall have
again to refer. Or, it may be produced in the medullary or cancellooi
tissue ; and here, commonly, it appears as a gradual thickening of the
minute cancellous lamellae and fibres of bone, which, as they increase,
gradually exclude the proper structures of the diploe or medulla, and
finally coalesce into hard solid bone.
But, by far the most common seat of the formation of new bone, and
that in which it is almost always found when it exists in either of the
former situations, is on the surface, between bone and periosteum, or
even in the periosteum itself. Here it forms the various growths to
which the general term Osteophyte has been given. lA a series of
specimens of common inflammation of bone or periosteum, it is not diffi-
cult to trace the changes of construction of the new bone, by which, like
that formed in a process of repair, it gradually approximates to con-
formity with the bone on which it grows. f
• KOstlin, Mailer's Archiv, 1845, p. 60; Rokitansky, ii. p. 172 j Virchow, in his Archiv, L
p. 135. •
t Any large Museum will supply such specimens. Those in the College of Surgeons are
minutely described in the Catalogue, vol. ii. p. 83, c. s., and vol. v. p. 43, e. s. : those at Sc
Biirtholomow's may be studied through the Indiccf*, pp. 1 and 57. Even different partsof a
single specimen will show much of what is described.
OABTILAGE. 287
At firsty it is, when dried, light and friable, with a close, filamentous,
rehrety texture, and a smooth surface, gradually rising from that of the
mntmnding healthy bone. As it increases in thickness it becomes lon-
■faldinally grooved, as if lodging bloodvessels passing, through it, from
Ip periofltemn to the old bone. Then, as fresh formations of new bone
dn place, they assume the form of nodules and thick plates, laid over
the longitudinal grooves, and leaving large apertures for the passage of
bloodvessels. Such plates, like nearly all bone new-formed in disease,
[iresent, at first, a porous surface and a finely cancellous lung-like tex-
kire. But, gradually, in whatever form, the new bone tends to become
kuder and heavier : the apertures that made its surface porous gradually
fiminiah till they are obliterated, and thus the new bone, while still
euicellous within, acquires a compact external layer, and becomes more
firmly united to the bone beneath it. The process of induration con-
timnng, the new bone acquires throughout a hard compact texture : its
outer surface, no longer porous, becomes nearly as smooth as that of the
dd bone ; its color also changes to that of the old bone ; and, finally,
the two unite so closely that the boundary line between them can hardly
be discerned.
Such is the gradual assimilation of the inflammatory product to the
characters of the normal structure from whose disease it issued : a
arocess peculiarly worth studying in the bones, because in them, more
hajk in any other tissue, the changes can be leisurely examined. Those
fhich I have described occur in common inflammations : such, e. g. as
!bllow injuries, or exist in the neighborhood of necrosis, or ulceration, or
!(ffeign bodies. They ar^ generally observed, also, in specific inflamma-
ions of bone : but among these it is worth observing how characteristic
>f difierent diseases are certain formations of the new bone. The
raatoles of variola, or the vesicles of herpes, are scarcely more charac-
;eristic of those diseases, than are the hard nodules of cancellous
i>one, clustered about the articular borders of bones that have been the
leat of chronic rheumatism ; or the porous, friable, dirty, and readily
ulcerating thin layers formed on the shafts in syphilis. "*"
Cartilage, I have said, is probably not formed in inflammatory
[ymph in the process of its ossification. Neither does it appear to be
formed in the more acute inflammations of articular cartilage : but, we
must not exclude it from the possible developments of inflammatory
products, while we remember the observations of Mr. W. Adamsf
respecting the enlargements of the ends of bones in chronic rheumatic
irthritis. In these, which are marked by such formations of new bone,
ind such thickenings of fibrous tissue, as we constantly ascribe to in-
lammations, there is manifest increase of the articular cartilage, and a
mbsequent ossification both of that which is new-formed, and, more
* As in Nos. 572, G28, and others, in the College Museum,
t Trans, of Pathol. Soc. of London, yoL iii. 1851.
288 BBVELOPMENT OF LTMPH INTO
slowly, of that which normally covered the head of the bone. TIw
early conditions of the vicrease of the cartilage are not traced: but
that it depends on inflammation, rather than on true hypertrophy, if
probable, both from the concurrent signs and results of inflanmuitkilj *
and from the new cartilage falling short of the perfect characters of d|)
old ; for it has a fibrillated intercellular substance, and scattered nadi^ '
and is prone to ossification.
It remains that I should describe the adjunct structures of orj
inflammatory lymph. But this may be briefly done, because the accoimt
of the formation of new bloodvessels in granulations and other reparatire
materials might, I believe, be transferred hither (p. 145). The question
is, indeed, often raised, as in the corresponding instance of granulations
becoming vascular, whether the bloodvessels are formed entirely of the
material of the lymph, and, as it were, by its own power of develop-
ment, or whether they are outgrowths from adjacent natural or origioil
vessels, which, as the expression is, shoot out into the lymph.
I think it nearly certain, for the following reasons, that the lympli
forms neither vessels nor blood, but receives those that are projected
into it from the parts on or in which it is placed.
1. The direct observations supposed to prove that blood is formed in
lymph are very liable to fallacy, through the facility with which' blood
may be accidentally mixed with the lymph, in consequence of hemo^
rhage during life or after death, or in the preparation of the specimens.
Where these sources of fallacy have been avoided, I have never seen
anything suggestive of a transformation of lymph into blood.
2. The development of blood from tissue-cells is limited, naturally, to
the earliest period of embryo-life, as if it needed the greatest amount of
force for development ; afterwards, blood is not formed except through
a long process of elaboration, and with the aid of many organs. Its
formation, therefore, in the malconditions of inflammation is veiy
improbable.
3. In no specimen of inflammatory lymph have I seen appearances
of transitions from lymph-cells to blood-cells, such as we may see in the
lymph of the lymphatics, both before and after it is poured into the
bloodvessels.
4. Neither in any lymph have I seen appearances of such stellate
cells as the interstitial bloodvessels of the early embryo are formed
from ; nothing comparable with them has ever come into view.
5. In the formation of vessels for granulations and the walls of chronic
abscesses, all is favorable to the belief that they grow up from the blood-
vessels of the adjacent parts ; and there are no structures to which the
lymph bears so close analogy as it does to these, or to which it is so likely
to be conformed in the production of its vessels.
On the whole, therefore, although direct observations are wanting, I
239
: wo may conclude tliat all the vessels of inflummatory lymph are
ined by outgrowth from ailjacent vessels, as in the process of repair,
1 that through these vessels, not by its o^n development, it derives its
iy of blood.
the first instance, the bloodvessels of lymph appear to be usually
■ numerous and thin-walled ; therefore easily bursting, or dilated by
ngcstioDS during life, or in the attempt to inject them after death.
! College collection contains an
JKtremely beautiful specimen of soft
ncont lymph from the pericardium
t a Cheetah, the vessels of which,
Reeled by Mr. Quekett, appear as
Uunerous and close-set as those of
ne of the more vascular mucous
imbranes. They present occa-
lonal slight and gradual dilata-
Sons, especially when they branch
anafitomose.
But after an uncertain time, as
e lymph becomes more highly
IVganised, so its vessels waste and
fiminidh in number; and wliile it
iDquires the proper structure of the
iro-cellular tissue, so it descends
the low degree of vascularity of
Bt tissue. The vessels of false membranes,
represented here (I
M), from an instance in which they were naturally injected with blood,
usually rather wide apart,
leng, slender, and cylindriform.
h all these particulars they
USer from those of more re-
cently vascularised lymph ; and
leir changes are, in these re-
Ipecta, parallel with those of ^
'le vessels of granulations du-
dng the gradual formation and
^rfccting of scars.
Perhaps the most perfect in-
Bnce of the confonnily with
LB natural tissues of the body
I which the developed lymph
attain, is manifested in its acquiring a supply of lymphatic ves-
. We owe the knowledge of the lymphatics of fulae membranes to
masterly skill of Professor Schroeder van der Kolk, whose prepara-
ions of them are described and represented by his pupil, Dr. de Les-
240 DEVELOPMENT OF LTMPH.
pinasse."*" In fig. 35, copied from one of his plates, beautifol network
of lymphatics, with their characteristic beaded forms and abimdant
anastomoses, are shown traversing adhesions extending between two
lobes of a lung ; while yet closer networks are seated in the thickeMl •
and opaque-white substance of the pleura, or of false membrane coveriig
it, beneath the adhesions.
It seems to be in only the most perfect state, and when bloodveflsda
have long existed, that lymphatics are formed in false membranes. In
recent lymph Schrocder v. d. Kolk has never succeeded in injecting any;
and we can only suppose that they are, like the bloodvessels, prodaoei
by outgrowth from the lymphatics of the membrane with which they are
connected.
Virchowf has twice seen nerve-fibres in adhesions. In one case, tiro
fine nerve-fibres passed through an adhesion of the pleurae ; in the other,
a single fibre extended into, but not through, an adhesion between the
liver and diaphragm.
The time in which these complete developments of lymph may be
accomplished must vary so much, according to the circumstances of the
inflammation, that perhaps no reasonable estimate of it can be made.
The experiments of Villcrmd and DupuytrenJ upon dogs assign twenty-
one days as the earliest time in which new vessels are formed ; but I am
disposed to agree with Dr. Hodgkin, that a shorter time is sufEcient
On the other hand, I am sure that the supposition of their being formed
in one or two days is incorrect. The principal case in support of thk
opinion is that recorded by Sir Everard Home ; but the specimens pre-
served in the College Museum§ show that he was deceived as to the true
nature of the case. He says|| that he operated for strangulated hernia
in a man, and found in the sac a portion of ileum, which was healthy,
except in that its vessels were turgid with blood. The patient died
twenty-nine hours after the operation ; and on examination " several
small portions of exuded coagulable lymph" were found adhering to the
intestine that had been protruded. When the vessels of the intestine
were injected, the injection passed into vessels in all these portions of
supposed lymph, each " having a considerable artery , . • . and a return-
ing vein.*' Sir Everard Home, therefore, concludes "that the whole
* Spec. Anat. Path, de Vasis novis Pseudo-mcmbrananim, Bvo. Daventria^, 1842, figs. liL
iy. In another instance he injected lymphatics in an adhesion between the liver and dia-
phragm. A similar injection of these in adhesions between an ovarian tumor and the small
intestines is described by Lebcrt : Trait6 des Maladies Gancereiises, p. 40.
t WQrzburg Verhandlungen, i. 144.
J Quoted by Dr. Hodgkin, in his Lectures on the Morbid Anatomy of the Serous Mem-
branes, p. 42.
§ Nos. 81 and 82 in the Pathological Museum.
II In his Dissertation on Pus, p. 41. The whole case is given in the College Catal(^pae,
vol. i. p. 37.
»ff
DieiHlBATIOHS 09 LTMPH. 241
of throwing out co«g«lable lymph, and supplying it with blood-
it had heoome solid, was effected in less than twenty^four
fToiTf one of these specimens was figured by Mr. Hunter,'*' ^^to show a
A poirtion of coagulating lymph .... which is supplied with vessels;"
Lnehher here, nor in his manuscript catalogue, does he allude to a
Mliifity of the ressels having been formed in twenty-four hours,
hough, had he believed it, he would scarcely have fedled to record it.t
I ofwaiainathm of the specimens show that the small, shred-like portions
membrane, attached by little pedicles to the intestine, have not the
paarance of recently coagulated lymph, but are fully organized, with
laas of filaments and fat-cells. They are also very regularly, disposed,
jBrtunrm of from half an inch to an inch from each other, and are
■rly all placed in two rows on each side of the intestine, about half an
A Itom the attachment of the mesentery, like very minute appendices
iploicse, such as are occasionally met with on the coats of the small
tastine. Whether they be such appendices or not, it is in the highest
igrae improbable that they were formed after the operation ; especially
Ma they are too minute and delicate to have prevented the intestine
wm ezhilnting, when exposed in the sac, the natural polished appear-
M of its surface.
I am not aware of any other case adapted to prove the earliest period
liriudi bloodvessels may be formed in lymph. Serous surfaces may,
wknij become adherent in twenty-four hours, but this does not imply
■iwliiity of the lymph between them ; it is simply adhesion by the
wptation of the intermediate lymph.
LECTURE XVL
DBeXNBRATIONS OF LTMPH.
EAYOra ^ven, in the last lecture, a general history of the chief deve-
jpnents of the lymph exuded in the inflammatory process, I propose,
vWy to tell a corresponding history of its degenerations ; and herein to
■cribe what appear to be the transitions, from the ordinary forms of
qih in its primary state, its fibrine and its corpuscles, to those many
Mr forma enumerated as molecular and granular matter ; as pus-cells,
MUil^HiellSy inflammatory globules, and the rest.
• Wotlu, pL XXL flg. 2.
tin the Traadte on the Bkx)d (Works, toL ill. p. 350) he ipeakt of nine days as a short
M lor die eompkftd otgeniiation of adhesions.
IS
242 DEGENERATIONS OF THE FIBBINB OF LTMPH.
I said that, for the deyelopment of Ijmph prodac«d in inflamnuitioD,
it is requisite that the inflammation shall have ceased, and the conditioiii
of healthy nutrition be restored. In the failure of this event, if tibe
inflammation continue, or the due conditions of nutrition be in any iray
suspended, then, instead of development, degeneration will occur, viA
more or less rapidity, according to the original character of the lyn^
And this may happen in any of the stages of formation which I described
in the last lecture : it may happen alike to the rudimental fibrine, or to
the earliest lymph-cell, or to either, in any part of its progresB to cmq-
plete development.
The following appear to be the chief degenerations of the fibrinon
part of lymph, or of the materials derived from its earliest stages of
development, whether in the purely fibrinous, or in any of the nuzed,
forms of lymph : —
1. It may wither : wasting, becoming firmer and drier, passing into a
state which Rokitansky has designated homy. One sees the best exam-
ples of this change of fibrine in the vegetations on the valves of the
heart, or in the large arteries, when they become yellow, stiff, elastie,
and nearly transparent. The fibrine may, in this state, show no marb
of development into tissue, but may have all the simplicity of stmoture
of ordinary fibrine, being only drier and more compact. A neaily
similar character is acquired when lymph is deposited over a lung whidi
is extremely compressed in empyema, or in hydrothorax. The toof^
dry lymph that here forms the grayish layer over all the long, is not
always developed, though it may adhere firmly: it may be withered,
wasted, and dried (as the lung itself may be), apparently in consequence
of the compression.
2. The fibrine of lymph is subject to a degeneration which we may
compare in many respects with fatty degeneration, or, more closely, wiA
the changes by which lymph-corpuscles are transformed into those of pus^
with which changes, indeed, this is commonly associated in the mixed
forms of lymph. In the solid parts of efiusions, that are found in the
lower forms of inflammation, or in very unhealthy persons, the fibrine of
the lymph is usually not clear and uniform and.filamentoiis, but rather
opaque or turbid, nebulous or dotted, presenting just such an appearance
as marks the earliest stages of fatty degenerations in the muscular fibrils.
In such lymph, also, one sees, not unfrequcntly, minute, shining, black-
edged particles, which we may know to be drops of oil: while some
general alteration in the composition of the fibrine is shown by its not
being made transparent with acetic acid. In all such cases as these the
fibrine is very soft, and easily broken : it is devoid of all that toughness
and elasticity which is the peculiar characteristic of well-formed fibrine;
and by breaking it up, one may see the meaning of what one so often
finds in the lowest forms of inflammatory exudation, such as occur in
erysipelas and typhus ; namely, films and fragments of molecular and
BSeSirSBATIOKS OF THE FIBBINE OF LTMPH. 248
tted substance, floating in fluid that is made turbid by them, and by
mdant minute molecules and granules and particles of oily matter.
mt represent the diedntegration of fibrine that has degenerated after
lling, or has thus solidified in an imperfect coagulation. Of such
■tges, also, an excellent instance is presented in the softening and
int^ration of clots within the heart, which Mr. GkOliver'*' first de-
ibed. These, indeed, or any of the instances of the apparent suppu-
iotk within clots in the bloodvessels, might be studied for the illustra-
B of the corresponding changes in inflammatory lymph ; especially, in
ation to the likeness which, in both cases, the degenerate fibrine bears
die molecular matter in the thinner and more turbid kinds of pus.
Wt have examples of numerous varieties of this degenerate and disin-
;rated fibrine exuded in inflammation. It is a principal constituent of
•t of what has been called ^^ aplastic lymph," in inflammation of the
008 membranes. Similar fibrine occurs, mingled with mucus, in the
fcrer inflammations of the mucous membranes. And to the same
iree we may trace much of that molecular and granular matter which
■soally mingled with all the less perfect forms of pus : e. g, with that
med in the suppuration of chronic inflammatory indurations ; with the
riondy changed corpuscles of '^ scrofulous matter ;" or with the granule-
Bi, and other corpuscles of pneumonia, and the like inflammations.
The general characters of the materials here described, and the coin-
lent changes ensuing in the corpuscles that may be mingled with the
ffine, make it probable that the changes are of the nature of fatty
generation occurring in the fibrinous lymph. But when, as I have
id elsewhere (p. 157), we see how a large mass of inflamed hard sub-
laoe will become fluid, as it suppurates, and this with scarcely any, if
ij, increase of bulk, we may believe that another change ensuing in
a fibrine is that which I called liquefactive degeneration (p. 78.) In
dk a swelling, we may be nearly sure there is coagulated fibrine, both
om the general circumstances of the inflammation, and because neither
iposcles alone, nor fibrine in the liquid state, would give such hardness.
be suppuration, therefore, if without increase of bulk, can hardly be
jdained, except on condition of the fibrine, which had solidified, be-
ming again liquid. The occasional liquefaction of clots out of the
djt makes this more probable; but I am not sure that it can be
ured by any more direct facts.
A point of some practical importance is connected with these forms of
generation of lymph, whether afiecting fibrine or corpuscles. When
) fibrine has withered and become dry, it is probably put out of the
Mcity of being further developed, and is rendered passive for further
' MedicoOiinirgicml Tninwctions, toL zxii. p. 130.
' As in eafet by Natie and De la Harpe, quoted by Henle, in hit Zeitschrift, E ii. p. 169.
! alio Yirchow on the lame subject, in the lame Zeitschrift, & iv. Henle refers to this
ie Uqnejbction tlie changes that ensue in emitted semen.
244 DBCIBNBBATIONS OF THB FIBRIHB OF LTMPH.
harm or good, except by its mechanical effects. Bat the fattj and
liquefactive degenerations may be yet more beneficial, in that they bring
the lymph into a state favorable to its absorption^ and, therefore, fkYOt^
able to that which is termed the " resolution " of an inflammation in whidi
lymph has been already formed. I suppose it may be oonndered as a
general truth, that the elements of a tissue cannot be absorbed so lonf
as they retain their healthy state. There is no power of any absorbent
vessels that can disintegrate or decompose a healthy portion of the body;
for absorption, there must, in general, be not only an absorbing power,
but also a previous or concurrent change — as it were a consent — in tbe
part to be absorbed ; so that it may be reduced (or, rather, may redaoe
itself) into the minutest particles, or may be dissolved. And this change
is probably one of degeneration, not death, in the part ; for dead matter
is usually rather discharged from the body than absorbed.
Now such degeneration of the fibrine products of inflammation as I
have described, brings them into a state most favorable for absorption;
indeed, one may see in lymph thus changed many things whioh, in regud
to the fitness for absorption, would make it parallel with chyle.* Of
such absorption of fibrine we may find many instances. In rheumatic
iritis we may believe the lymph to be fibrinous ; but we see its complete
absorption taking place; and the observations of Dr. Eirkes on the
rarity of adhesions of the pericardium, in comparison with the frequenoj
of pericarditis,t may be in the same manner explained. In rhenmatio
pericarditis we may be sure fibrine is exuded ; and the observed friction-
sound has, in some cases, proved its coagulation ; yet in these cases, when
death occurred months afterwards, scarce a trace of fibrine was found in
the pericardium : it had been absorbed, and the degeneration I have been
describing was probably the preparation for its absorption.
8. I am not aware of any direct proof of the calcareous degeneration
ensuing in the fibrinous part of an inflanmiatory exudation ; but we have
the strongest evidence from analogy for believing that this change may
be a frequent one. For there are numerous instances of calcifications of
fibrine within the vessels : as, e. g. in the ordinary formation of phlebo-
lithes from clots of blood, in the branching and irregular pieces of bone-
like substance found in obliterated veins, and in the lumps and grains of
substance like mortar imbedded in fibrinous deposits on the heart's valves.
We can, therefore, hardly doubt that the fibrine, even before develo|h
ment, may take part in formations of earthy matter in inflammatory
products ; but the calcareous degeneration seems much more frequent in
purulent fluids, and in the later developments of lymph.
4. Lastly, we have examples of the pigmental degenerations of fibrin-
ous lymph in the various shades of gray and black which often pervade
* See also the ingenious contrast of the progress of chyle and the regress of pus diawn
by Gerber, in his Allgem. Anatoniie, p. 49.
t Medical Gazette, April, 1849.
BKeXKBBATIOKS OF THE CORPUSCLES OF LTMPH. 246
the lymph formed in peritonitis, and which are prodnced, not by staining
er discoloration of the blood by intestinal gases, but, according to Roki-
tuuiky, by the incorporation of free pigment-granules.
Such appear to be the degenerations of the fibrine of inflammatory
fymph : Buch at least are the changes in it which we may refer to de-
fceta in its power or conditions of nutrition, because they correspond with
dhangea that may be traced in the gradual degenerations of old age. I
need hardly say, that it is chiefly by such correspondence that we can
interpret them ; for when we find them, it is often beyond our power to
teD, by direct obserration, whether or in what way, the oonditions of
nutrition were defeotive.
Hie corpuscular constituents of lymph, in any of their stages of de-
Telqimenty may retrograde, and present degenerations corresponding and
usually concurrent with those which I have just described.
1. Their withering is well seen in some forms of what is called scro-
fulous matter, such as occurs in chronic and nearly stationary scrofulous
enlargements of lymphatic glands. In the dull ochre-yellow-colored and
half dry material imbedded in such glands, may be found abundant cells,
Bueh as are sketched in fig. 36. They are collapsed, shrivelled, wrinkled,
glistening, and altogether irregular in size and form. One might sup-
pose them to be the remnants of pus dried up, or the corpuscles of chro-
iiie tdbereulous matter, if it were not that among them are some with
iiadri shrivelled like themselves, and some elongated and attenuated,
whidi are evidently such as withered after they had been developed into
the form of fibnx^lls ; into which form it is certain that neither pus-
eorpusdea nor those of tubercle are ever changed.
vii.as.
t'jt\
^ ^-
\l
\
i'
/
These are the best examples of withered lymph-corpuscles ; but they
may be also found in the pus of chronic abscesses, especially, of course,
in that of such abscesses as ensue by suppuration of lymph-deposits like
those just referred to. It may be hard, sometimes, to say whether cor-
puscles in these cases may not be pus-corpuscles shrivelled up, but on the
whole, I am inclined to believe that the shrivelled corpuscles of the pus
of chronic abscesses are usually derived from the lymph, in which, having
withered, they had become incapable of further change.
2. The fatty degeneration of lymph-cells is shown in their transition
iDto granule-cells.* We owe the first demonstration of this to the ex-
* The inflammatory globales of Gluge.
246 DHeBNERATIONS OF THE C0BPU80LB8 OF LTMPH.
cellent observations of Reinhardt,* who has also shoim how, by similir
degenerations, corresponding forms of grailule-cellB may be derived bm
the primary cells of almost all other, both normal and abnormal, stno-
tures.t
This method of degeneration appears peculiarly apt to occur in tin
inflammations of certain organs ; as, especially, the lungs, bram, aad
spinal cord ; but it may be found occasionally prevalent in the lymph of
nearly all other parts and in the granulations forming the walls of ab-
scesses or of fistulse. It may occur alike in the early forms of lymph-cdb,
and after they have already elongated and attenuated themselves, as for
the formation of filaments, and after they have degenerated into pn-
cells. The changes of transition (as shown in fig. 87), are, briefly,
these : — ^The lymph-cells, which may have at first quite normal charM-
ters, such as I have described (p. 217), present a gradual increase of
Hg. 87.
shining, black-edged particles, like minute oil-drops, which aocumulatein
the cell-cavity, and increase in number, and sometimes in size also^ till
they nearly fill it. The fatty nature of these particles is proved by their
solubility in ether : and their accumulation is attended with a gradual en-
largement of the cell, which also assumes a more oval form. Moreover,
while the fatty matter accumulates, the rest of the contents of the cell
become very clear, so that all the interspaces between the particles are
quite transparent ; and, coincidently with all these changes, the nudens,
if any had been formed, gradually fades and disappears, and the cell-
wall becomes less and lesif distinct.
I need hardly say, that, in these particulars, the changes of the lymph-
cells (which may also occur when they have been already developed into
the form of fibro-cells), correspond exactly with those of the fatty dege-
nerations observed in the cells of the liver or kidney, or in the fibres of
the heart. There can be hardly a doubt of the nature of this process :
and it presents an important parallel with the similar changes described
in fibrine. For, we may observe, first, that where this degeneration is
apt to occur in lymph, it is least likely to be developed. A proper indu-
ration and toughening of the lungs and brain, such as might happen
through development of the products of inflammation, is extremely rare;
• Traube's Beitrftge, B. ii. 217.
t Observations similar to those of Reinhardt were made independently by Dr. Andrew
Clark. (Medical Gazette, vols. xlii. xliii.) See also Dr. Gairdner's description of the fbr-
mation of granule-cells from epithelium-cells in pneumonia (G)ntributions to the Pathology
of the Kidney, p. 20); and the list of references, p. 105.
INILAMMAIORT SUPPURATION. 247
it IB rarely seen, except in the acars by which the damages of disease are
kealed. And, besides, this degeneration is a step towards the absorption
of the lymph ; for commonly we may trace yet later stages of degenera-
tion in these granule-cells. They lose their cell-walls, and become mere
masses of granules or fatty particles, held together for a time by some
peUncid substance, but at last breaking up, and scattering their compo-
nents in little clusters, or in separate granules.
Thus, if at no earlier period of their existence, or after no fewer
diangee, the lymph-corpusdes may pass into a condition as fayorable for
absorption as is that of the fibrine when similarly degenerate and broken
up : and such as this, we may believe, is a part of the process by which
IS accomplished that ^^ clearing up" of parts indurated and confused in
inflammation, and, especially, that of the solidified lung, which is watched
with BO much interest in pneumonia.
8. Calcareous degenerations of the lymph-cells appear in cases, such
as Henle* refers to, in which granule-cells are composed not wholly of
&tty matter, but in part also of granules of earthy matter. In this com-
binaticm they correspond with a common rule ; for the fatty and earthy
degenerations are usually coincident : they are combined in the advanced
stagee of the degenerations of arteries, and may be said to have their
nomud coincidence in ossification.
4. Of the pigmental degeneration of lymph-cells there are, I suppose,
examples in the black matter effused in peritonitis : but the best examples
are in the cells in bronchial mucus, to which I have already referred (p.
m).
The most frequent degeneration of inflammatory lymph is into pus.
It may ensue in nearly all the cases in which lymph is placed in condi-
tionB unfavorable to its development ; as in the persistence of inflamma-
tion, or in exposure to air, or in general defects of vital force. -It affects
alike the fibrinous and the corpuscular parts of lymph. For although
we do not call any liquid ^^pus," unless it have the characteristic pus-
eorpusdeB, yet the materials of degenerate fibrine are conunonly mixed
with these ; and indeed many of the varieties of the pus formed in inflam-
mationB owe their peculiarities to the coincident degenerations of the
fibrine.
The facts proving the transformation of inflammatory lymph into pus
oorrespond very nearly with those already cited (p. 155) concerning the
flimilar relations of granulations to pus in the process of repair. But a
few may be mentioned here : —
1. The fluid of such vesicles as those of herpes, is, in the first instance,
a pure inflammatory lymph, containing corpuscles which might be taken
as types of the lymph or exudation-corpuscles, and which may be as
easily distinguished from any cells of pus, as the cells of well-formed gra-
• In his Zeitachrift, B. ii
248 IKFLAMMATORT SUPPUBATIOK.
nulations may be. If we watch these vesicleSy we see their oontentB nol
increased, — ^rather, by evaporation, they are diminished ; but the lymph
is converted into pus, and pus-cells are now where lymph-cdls woii
And the change may ensue very quickly : I think I have known it
accomplished in twelve hours at the most.
2. In like manner, as I said before (p. 157), when we watdi the priK
gress of an abscess, we may find one day a circumscribed^ hard, aid
quite solid mass, and in a few days later the solid mass is fluid, and tUa
with little or no increase of bulk. Now the solidity and hardneas an
due to inflammatory lymph ; the later fluid is pus ; and the change la tba
conversion of lymph into pus.
3. As in common suppuration of a granulating wound, the granulik
tion-cells appear to be convertible into pus-cells ; superficial oeDa baiag
detached in pus, while deeper ones are being developed into filaments;
and as in worse-formed granulations, the cells are often by no charactsn,
except by their forming a solid tissue, distinguishable from pua-cella; n^
in an inflamed serous membrane, pus-cells may float in the fluid, aook
as cannot be distinguished from cells in the vascniarised lymph tkat
lines the cavity. In the fluid exudation, and in that which ia solid, Ai
same forms may be found ; though, by comparison, we may be able to
trace that in the former none of the cells were being developed, smI
many were proceeding beyond the degeneration to whidi any had
attained in the latter.
3. One may see the same conversion of inflammatory lymph into poi
thus illustrated. An amputation through the thigh was performed lAan
all the parts divided were infiltrated with lymph, effused in connexion
with acute traumatic inflammation of the knee-joint. Next day pas
flowed freely from the wound. Now, in amputation through healthy
tissues, free suppuration does not appear till after three or four days:
the pus here seen must have been formed by the conversion of the inflaah
matory lymph previously infiltrated in the divided tissues.^ Similar
facts may be less strikingly observed in any wound.
From these and the like facts we have an almost exact parallel, in
their relations to pus, between the material for repair by granulationa
and that exuded in the inflammatory process ; and between, if they Buy
be so called, the reparative and the inflammatory suppurations. And in
some of the facts we may trace a transition from the one proceaa to the
other. In the formation of an acute abscess, for example, inflammatoiy
lymph is transformed into pus ; then the pus, say, is discharged ; tiM
signs of inflammation cease ; the process of repair is established, and
* These facts, while they prove tliat the pus-cells are commonly the result of degenera-
tion of lymph-cells, may also serve to show that the question often asked, whether pas-oelli
are ever an original or primary product of inflammation, cannot be precisely answered. We
cannot always discern a preliminary lymph-stage; but neither can we alwayi distingniih
lymph-cells from pusKsells, whether in serous fluid or in mucus, nor can we say in bow
yeiy brief a time tlie transformation from the one to the other may be accomplished.
ABSCESS. 24d
nepumtiTe gmralations line the abscess-cavity in the place of, or formed
hjj the peripheral layer of the lymph. Now, pus continues to be
formed ; bat this pus is derived, not from inflammatory lymph, bat from
graaidatioii-sabstance. So, also, when an inflamed part is cat, the first
poi IB from lymph : the latter pas, when repair is in progress, is from
gnukolatioii-^abstaiice. In both cases, alike, the pus manifests itself as a
mdimental sabetance ill-developed or degenerated (see p. 156) ; and the
trusition from Ae one condition to the other is an evidence of the
imponibility of exactly defining between the inflammatory and the repa-
lative processes, unless we can see their design and end.
Much, therefore, of what was said respecting suppuration in connexion
with repair, might be repeated here. But, avoiding this, let me only
point out the principal methods in which inflammatory suppuration en-
SM8) and the relation of the pus in each to the previous or coincident
inflammatory product. In this last respect, the suppuration of disease
differs importantly from that of the reparative process, in that the de-
generatioa may take place in any of the difierent varieties of lymph,
and that according to the primary character of the lymph, there may be
tneed (though as yet too obscurely) different appearances of the pus.*
The methods of such suppuration may be named the circumscribed,
the difiuse, and the superficial. The first may be exemplified by the
fonnation of an abscess or a pustule ; the second by phlegmonous erysi*
pdas, or purulent infiltration of any organ ; the third by purulent oph-
thalmia^ or gonorrhoea : and in these and the like instances we may
ofken, at the close of the disease, watch the transition from the suppura-
tion that depends on the inflammatory process, to that which is coin-
cident with repair.
In circumscribed suppuration, which has its most usual seat in th^
eeDolar tissue, we can generally observe the previous signs of inflamma-
tion, and of an exudation of lymph in a certain area of the tissue. The
exudation is interstitial, or by infiltration ; and, probably, in most acute
tbeoesses, b of a mixed kind, containing both fibrine, which may solidify,
and a liquid material of which corpuscles may form themselves. The
proper elements of the tissue are separated or expanded by the lymph
thns inserted among them ; and the inflamed part derives from it much
of its swelling, and much of its hardness while the fibrinous part of the
Ijmph 18 solid. Generally, such a swelling is at first, comparatively,
BMefined ; and if it be near the skin, the visible inflammatory redness
very gradually fades-out at its borders, where, in the deeper tissue, we
may believe, the exudation is gradually less abundant. But, in time,
the swelling usually becomes more defined ; the inflammation, as it were,
eonoentrates itself, and appears more completely circumscribed. Now
die lymph, in such a case, may be absorbed, or may be developed so as
to form a long-continuing thickening and induration of the part : but, in
* See especially Rokitansky: Pathol. Anat. B. i. p. 210.
250 ABS0B8S.
the case I am supposing, it is transformed into pus; its corpusdes ohaiig^
ing their characters in the manner already described (p. 166), and ite
previously solidified part becoming liquid. The change almost slwajs
begins at or near the centre of the lymph, where, we may believe, Aa
conditions of nutrition are most impaired. It may extend from a single
point, or from many which subsequently coalesce. In either case, die
central collection of matter remains surrounded by a border or wall of
indurated tissue, in which the infiltrated lymph is not transformed into
pus, but, rather, tends to be more highly organized. This border or
peripheral layer of lymph now forms the wall, as it is called, of the tb-
scess, and the finger may detect, as the best sign of abscess, a soft or
fluctuating swelling with a firm or hard border. The expressions ooib-
monly used are, that the suppurative inflammation has taken place in
the centre of the swelling, and that its effects are bounded by the adhe-
sive inflammation : it might be said, with the same meaning, but perhaps
more clearly, that, of a certain quantity of lymph deposited in the ori^
nal area of the inflammation, the central portions have degenerated into
pus, and the peripheral have been maintained or more highly developed:
and, probably, we may add in explanation, the difference has depended
on the degrees in which the conditions of nutrition have been interfered
with in the places in which the two portions have been seated. In the
central parts of an inflammatory swelling, the circulation, if not wholly
arrested, miist be less free than in the peripheral ; the blood, moving
very slowly, or stagnant, must lose more of its fitness for nutrition ; the
tissues themselves are more remote from the means of maintenance by
imbibition : in these parts, therefore, degeneration, if not death, ensaee;
while, in the peripheral parts, maintenance, or even development, is in
progress.*
Now, in the ordinary course of such an abscess, the purulent matter
is discharged. (I shall speak in the next lecture of the manner in whidi
this takes place, as well as of the changes that ensue in the tissues among
whose elements the lymph is infiltrated.) On the interior of its wall,
especially if its course have been very acute, we may find a thin, opaque,
yellowish- white layer, easily to be detached, flaky, or grumous. It ii
usually formed of lymph-cells or pus-cells imbedded in flakes of soft
fibrinous substance. It has been made to seem more important than it
is, by being called by some a ^^ pyogenic membrane," and by its being
supposed that it is the work of the cells to secrete the pus. But the
* Expressions are sometimes used which imply that the wall of the abscess is formed bf
an adhesive inflammation following, and purposely consequent on, the suppurative. This
certainly happens, if ever, very rarely : it only seems to take place when sappuratioD ii
accompanied by extending inflammation. In such a case, that which is to-day the indurated
abscess-wall, may, to-morrow, have become pus; and new inflammatory products, dejinsited
around it during its degeneration, will form then, the boundary of the enlarged abscc>6. It
may be, indeed, that the lymph deposited at the centre of the inflnmmatory process i*.
naturally, less organizable than that at the periphery ; but this is not proved.
ABSOXSS. i&l
enee of nioh a kjer is far from coiutajit in absceasefl ; it is, often,
n of the imperfect organisation of the absceas-wall ; its materials
jNTobablj oftflner detached and mingled with the pus than they are
ilariied ; and no aaeh layer is found when free suppuration continues
1 open abscess. A more normal coarse is observed when the pro-
I of suppuration has been slower. In this case, the wall of the ab-
becomes more highly organized after the discharge of the contents ;
arcolation beinjuestored in the infiltrated tissues of which the vail
naed, the Ijm^ is developed, or at least, if I may so speak, more
ly virified, and its cells, or new ones formed next to the abscess-
,y, are constraoted into granulations, and are supplied with blood-
^ like those on the surface of a healing suppurating wound. Such
^ are represented in this sketch.
tthf or soon after, the evacuation of the pomlest matter, the disease
hich the abscess depended may cease : and, if this be so, the later
nsB of the case is a process of healing wbich may, in every essen-
sharacter, be likened to the healing of a wound by granulation.
t ia the same gradual development of the lymph-cells, or, as they
t DOW be called, the granolaUon-cells of the walls of the abscess, — ■
ai the deeper, and then of the more superficial cells. The same
action, also, attends this process, tuid serves to diminish the area of
avity, and to bring its walls more nearly into correspondence and
mity with the external opening, till, coming into contact, the oppo-
nrfices of granulations may unite, as in healing by secondary adhe-
; or till, as the edges of the opening are retracted and depressed,
ihe floor of the abscess is raised, they are brought nearly to a level,
tieal as a single granulating surface.
eh an abscess as I have described is often called acate or pblegmo-
in contradistinction from those collections of pus which, being formed
mt the observed signs of inflammation, and, generally, slowly, are
)d cold or chronic abscesses. Observations are wanting, I believe,
li might show how far the chronic abscesses differ from such as I
described in their early condition ; and, especially, whether there
25S DIFFUSE SUPPURATION.
be first a circnmscribed infiltration of lymph, of which part degeneratei
and the rest is developed. It is probable the phenomena are essentiilly
the same ; for instances of all possible gradations between the two fonn
may be obserred ; and, in the complete state of the chronic ahsoess, tlie
stmctnres are not widely different from those of the acute. The absee^
wall is usually firmer, more defined, so that it can often be dissected »
tire from the adjacent parts, and has its tissue more developed, and nun
like those of a membranous cyst : the lining is flperally less Tascnlar,
smoother, and less distinctly granulated ; the coiilS^ts are usually thin
and serous, and indicate not only that the material of which they tn
composed was peculiarly unapt to be organized, but that, even after its
transformation into pus, further degenerations ensued in it.
The diffuse suppuration, as I have said, may be exemplified by phleg-
monous erysipelas. Here, with well-marked phenomena of inflammadon,
lymph is exuded through a wide extent of the subcutaneous cellular tissue^
and, from first to last, the boundaries of the exudation are ill-defined:
the suppuration is, indeed, most certain and complete at the centre, or
where the inflammation began ; but it may bo nearly coextensiye wiA
the exudation, and most rarely presents a well-defined boundary-wall, u
in abscess. The lymph, in its primary character, is mixed ; its fibrinous
constituent is evident in the coagulation that ensues when it is let out (see
p. 213), and, usually, in the abundant molecular matter in the pus. Tbt
exudation is even more distinctly interstitial than in an abscess ; the tissne
is thoroughly infiltrated with it, and is, comparatively, little expanded :
and when suppuration has ensued, and we cut into the inflamed pttrts,
the pus often flows out slowly, or even remains entangled in the tissue.
The same condition is, often, yet more plain in the purulent infiltratittH
of such organs as the lung ; their tissues are completely soaked with pm.
The infiltrated tissues themselves are usually softened, not only by Ae
mixture of the unorganized inflammatory matter, but through their own
degeneration ; and, very generally, large portions of them perish, and
are found as sloughs infiltrated with pus.
In regard to their structural changes, there may appear little difierenee
between this condition and that of acute abscess, except in the contrast
of the one being less, the other more circumscribed. But in regard to
the materials exuded, they are, probably, in the phlegmonous erysipelas,
much less naturally apt for organization than in the abscess. The cen-
tral suppuration of an abscess, while the lymph around is organizing, inh
plies that the degeneration depends much on the local defect of the con-
ditions of nutrition : the diffuse suppuration seems due, in a larger mea-
sure, to original defect of the lymph ; and these differences correspond
with those of the constitutional states attending the two diseases.
After the discharge of the pus, the healing of the diffuse suppura-
tion is, in all essential respects, similar to that of the abscess ; but the
8UPB&FI0IAL SUPPURATION. 258
methods of discharge are much more (liverse. Sometimes, after extensive
aloughing of the skin, widenspread suppurating cavities are exposed, which
then gnmulate and heal like wide-open wounds ; sometimes, numerous
isolated suppurations ensue, whence the pus is discharged as firom so
many omall ill-defined abscesses, in each of which ordinaiy healing oc-
Gun, while the intermediate parts are indurated by the imp^ect organi-
ntion of the lymph ; sometimes, from a comparatively small opening,
large slou^^ are discharged, and then the boundaries of the subcutane-
ous cavities which they leave granulate, and healing takes place as by
secondaiy adhesion.
The sn^rficial inflammatory suppuration is such as we observe in go^
norrhcea, and in purulent ophthalmia, and generally in the inflammations
of mucous membranes. Here, the material exuded is least apt for or-
ganization, partly because of the situation in which it is produced, and
through its own natural condition ; for though exudation takes place, in
these cases, within the tissue of the inflamed membrane, as well as on its
Borface, yet the amount of thickening, or other structural change, that
takes place is slight, if we compare it with the changes that, in the same
duration and severity of inflammation, would ensue in fibro-cellular tissue,
or in serous membranes.
I have already spoken of the changes of mucus in the inflammatory
process, and of the mixture of lymph that then occurs. The lymph is
chiefly of the kind that forms corpuscles ; and there is no instance in
which the rapidity of formation of such corpuscles, and of their change
into the characters of pus-cells, can be watched. It is, indeed, chiefly,
in some of these cases of inflamed mucous membranes, that one may doubt
whether it is reasonable to speak of the formation of lymph-cells as pre-
ceding that of pus ; for, especially in the more acute inflammations, the
characters of pus-cells seem to be acquired in the very beginning of or-
ganiiation of the exuded liquid. And this character of the cells is often
retained, even after the product of the inflamed membrane has regained,
to the naked eye, a more mucous appearance; for here (unless ulceration
of the membrane have ensued) the process of recovery from inflammatory
suppuration is not through such healing by granulation, as in the former
caioe, but by a gradual return to the secretion of a more normal material ;
and in this recovery, the inflammatory exudation becoming gradually less,
the corpuscles that are formed, though they may assume the characters
of pus-cells, are not sufficient to give a purulent character to the liquid.*
* The question of the diagnosis between mucus and pus should, perhaps, be here referred
to. Between normal mucus and pus there can be no confusion (see p. 225). Between
the nnicos and the pus of an inflamed mucous membrane, the difi*erence corresponds, in some
meamre, with that between lymph and pus ; depending, first, on the proportion in which
the inflammatory material is mingled with proper constituents of the mucus, and, secondly,
on the degree in which the former tends to assume the purulent characters. In other wordf,
the diagnosis required is not, strictly speaking, so much between mucus and pas, as between
the lymph and pus which are, in difierent cases, mingled with the tnucut of \uQiiiv«A. m«iik>
254 INFLAMMATORT SUPPUBATIOK.
The superficial suppnration from inflamed mucous membranes is closely
related to that from an ulcerated surface. I think, indeed, that an
inflamed mucous membrane may yield purulent matter, even though it
remain covered with an epithelium. I believe this happens in gonorrfacM
and in purulent ophthalmia : the vascular tissues, in these affeetioDSy
appear still to have epithelium on them, though perhaps it is too tbin
and immature, and is reduced to a condition analogous to that of tlie
thin and moist glistening epidermis on the inflamed ^^ weeping" leg.
But observations are wanting on this point. The transition to the sup-
puration from an ulcerated surface takes place when the epithelinm m
wholly removed from a mucous membrane. This constitutes its abrasion
or excoriation ; in the next stage, the surface of the membrane itself is
cast ofi*, and this is its ulceration or erosion.*
Such are the several chief methods of inflammatory suppuration, and
the relations of the pus to other products of the cUsease. In all tlie
cases, a point of contrast between pus and any form of lymph is to be
found in its complete incapacity for organization.
When once formed, the pus-cells, if they are retained within the body,
have no course but to degenerate further ; it is characteristic of their
being already degenerate, that they can neither increase nor develqie
themselves. Various corpuscles found in pus, besides those I have
already mentioned, may find their interpretation in these degeneratioDs;
for the pus-cells are prone to all the degenerations that I described ts
occurring in the lymph-colls.
They may wither, as in the scabbing of pustular eruptions, or in long-
retained and half-dried strumous abscesses.
Or, they may be broken up, whether before or after passing into the
fatty degeneration, which is one of their most common changes, and in
which they are transformed into granule-cells. It is this breaking up
into minute particles which, probably, precedes the final absorption of
pus.
Or, lastly, both the cells and the fluid part of the pus may alike yield
fatty and calcareous matter, and this may either remain difiiosed in fluid,
or may dry into a firm mortar-like substance.
It is to such degenerations as these, in various degrees and combina-
tions, and variously modified by circumstances, that we must ascribe the
diverse appearances of the contents of chronic abscesses, and of the
branes. And this diagnosis is one which it is easy to make, in many cases, according to
such characters of the corpuscles as have been already described ; but, in other cases, it is
impossible, if it so chance that the materials are in the transition-stage from lymph to pus.
* The whole of the subjects of this paragraph are clearly and yery fully illustrated, in
relation to the affections of the mucous membrane of the uterus and vagina, by Drs. Tylei
Smith and Hassal, in a paper which will appear in the 35th vol. of the MedicoChirur^cal
Transactions, and of which an abstract is in the Lancet and the Medical Times of July 31,
1852.
d
EGBHBBATIOirS AITD DI8BA8BB OF OBOANIZBD LTMPH. 255
bftences that remain when abscesses close without complete final dis-
■rge of their contents. In such abscesses we may find mixtures of
a-ceUs, granule-cells, and molecular matter, difiused in more or less
[dd ; or pus^ells, half-dried, shrivelled, and showing traces of their
rided nuclei ; or, all cells may be broken up, and their d Aris may be
md mingled with minute oily particles, which appear in such cases to
I always increasing ; or, with these may be abundant crystals of choles-
line ; or, such crystals may predominate over all other solid contents.
I yet other chronic abscesses (though, still, without our being able to
D why the pus should degenerate in these rather than in the foregoing
Mdiods), we find molecules of carbonate and phosphate of lime, mixed
idi fat molecules and crystals, which are difiused in an opaque-white
■id, and look like a deposit from lime-water, or like white oil-paint ;
ad as these contents dry, in the healing of the abscess, so are formtf
he mortar-like deposits and the hard concretions, such as are found in
ke substance of lymphatic glands, or other organs that have been the
Mti of chronic abscesses.
Time and patience would fail in an attempt to describe all the varieties
of material that may thus issue from the transformations of pus. What
I have enumerated are the principal or typical forms with which, I
kSeve, nearly all others may be classed ; though not without considera-
tion of the various substances that may be accidentally mixed with the
pa; as blood, debris of tissues, &c.
hi conclusion of this part of the subject, — of this biography of in-
hmnatory lymph, — a few words must be added respecting the degene-
ntions and diseases which may occur after it is completely organized,
lie degenerations to which I have now so often referred, may be
)lioerved in full-formed adhesions, or in the corresponding organized
liones in the substance of organs.
Of the wasting of adhesions wo often see instances in the pericardium,
there films of false membrane are attached to one layer of the mem-
brane, while the opposed portion of the other layer is only thickened
Hid (q»aque. A more remarkable instance is presented in a case by
Kehat, in which a man made twelve or fifteen attempts at suicide, at
teant periods, by stabbing his abdomen. In the situations of the more
VMent wounds, the intestines adhered to the walls of the abdomen ; in
tkose of the older wounds, the older adhesions were reduced to narrow
bands, or were divided and hung in shreds.
To similar wasting atrophy we may refer the extreme thinning and
perforation of false membranes, by which, as Yirchow"^ has well de-
■cribed, they became fenestrated like wasted omentum.
Of fatty degeneration I have seen no good examples in adhesions or
linular infiammatory products, but of calcareous degeneration, or of such
* Wanborg Yerhandlungeni B. i. p. 141.
256 DBQBHERATI0H8 AND^DISBAHIS OV OSeAVXlBD IiTMPHi
as present a combination of fatty and earthy matter, museams premt
abundant specimenfl. Among these are most of the plates of bone-lib
substances imbedded in adhesions of the pleura, in thickened and opaqw
portions of the cardiac pericardium, in the tunica yaginalia in old hydbo-
celes, in the thickened and nodulated capsule of the spleen, in tk
similarly altered mitral and aortic valyes. So, too, many of the so-oaDed
ossifications of muscles and ligaments are examples of calcareous degene-
ration of fibrous tissue, formed in consequence of inflammation of ihcN
parts, and imbedded, in masses of fibrous-looking bands, within Hm
substance. In some of these cases, indeed, there may be an approxiin-
tion to the characters of true bone ; but in nearly all, the earthy matter
is deposited in an amorphous form, and seems to take the plaoe of tks
former substance, as if, according to Bokitansky, it were a residue of tke
tMnsformation of the more organised tissue, whose soluble parts have
been, after decomposition, absorbed.'*'
Pigmental degeneration of adhesions may.be seen, sometimes, in thoee
of the pleura, in which black spots appear like the pigment-marks of tlis
lungs and bronchial glands-f Adhesions of the iris, also, may become
quite black, by the formation of pigment like that of the uvea.
Lastly, it must be counted among the signs of its attainment of com*
plete membership in the economy, that the organized product of inflam-
mation is liable to the same diseases as the parts among which it is
placed ; that it reacts like them under irritation ; is, like them, afiected
by morbid materials conveyed to it in the blood ; and, like them, may be
the seat of growth of new and morbid organisms. No more complete
proof of correspondence with the rest of the body could be afforded than
this fact presents; for it shows that a morbid material in the blood,
minute as is the test which it applies, finds in the product of inflammatioB
the same qualities as in the older tissue to which it has peculiar affinity.
The subject, however, of the diseases to which these substances, them-
selves the products of disease, are liable, has been little studied. I can
only enumerate the chief of them.
Lymph, while it is being highly organized, is often the seat of hemo^
rhage; its delicate new-formed vessel^ bursting, under some eztemil
violence, or some increased interior pressure, and shedding blood. SvA
are most of the instances of hemorrhagic pericarditis, and other hezw
rhages into inflamed serous sacs.
Even more frequently, the lymph, when organized, becomes itself tlie
seat of fresh inflammation. Thus, in the serous membranes, we miy
find adhesions, in the substance or interstices of which recent lymph or
pus is deposited ;X or^ in other cases, adhesions, or the thick^iings and
* Numerous specimens of the calcareous degeneration of adhesions ara in the G>Ueg>
Museum; e.g., Nos. 103, 1493, 1494, 1516, &c.
t As in No. 96 in the College Museum,
f As in No. 1512 in the College Museum. The specimen has some historic interest It
BBSTSUCTIVB BFFB0T8 OF INFLAMMATION. 257
{gfuitiiBB of parts, become highly vascular and swollen. It is, indeed,
very probMle that, in many of the instances of the recurring inflamma-
tioiis that we watch in joints, or bones, or other parts, the seat of the
djaeaoe is, after the first attack, as much in the organized product of the
fonner disease as in the original tissue.
I suppose, also, that to such inflammations of organized inflammatory
products, we may ascribe many of the occasional aggravations of chronic
inflammations in organs ; the renewed pains and swellings of anchylosed
jomts, of syphilitic nodes, and the like ; which are so apt to occur on
ezpoBure to cold, or in any otherwise trivial disturbances of the economy.
In saeh cases we may believe that the former seat of disease becomes
Bcnre inflamed, and that with it are involved the organized products of
its preyious inflammations. And in such cases there are, perhaps, none
of the effects of inflammation which may not ensue in the newly orga-
niied parts : evidently, they may be softened, or thickened and indurated,
ind made more firmly adherent ; or they may be involved in ulceration,
or may sloagh with the older tissues among which they are placed.
Lastly, the products of inflammation may be the seats of the morbid
deposits of specific diseases. In their rudimental state they may incor-
porate the specific virus of inoculable diseases, such as primary syphilis,
Turiola, and the rest ; and, when fully organized, they may be the seat
of cancer and tubercle.
LECTURE XVIL
CHANGSS PRODUCED BT INFLAMMATION IN THE TISSUES OF TUB
AFFECTED PART.
The account of the results of inflammation, in the tissues of the part
in which it has its seat, will include the chief among those destructive
processes which, I said in a former lecture (p. 212), may be reckoned as
a second division in the inflammatory changes of the nutritive process.
For I believe that all the efiects of inflammation are injurious, if not
destructive, to the proper tissues of the part in which it is seated. All
the changes I shall have to describe are characteristic of defect of the
normal nutrition in the parts : they are examples either of local death,
or of some of the varieties of degeneration, modified and peculiarly
accelerated by the circumstances in which they occur. The degenera-
tions are observed, most evidently, in the processes of softening and
is one of those by which, in 1808, attention was first drawn, by Sir David Dundas, to the
connexion between acute rheumatism and disease of the heart.
17
258 SOFTENING OF INFLAMED PARTS.
absorption of inflamed parts. These I shall, first, endeavor tg illustrate;
and then, after some account of the minute changes that are associated
with them, I will describe the process of ulceration ; reserying for an-
other lecture the account of the death of parts that may occur in inflim-
mation. Let me, however, at once state that the changes in the prqwr
tissues of an inflamed part are, generallj, of twofold origin. (1.) Thej
are due to the natural degeneration of the tissue. That degeneratJon,
which would be progressive in the healthy state, but which would then
be unobserved, being constantly repaired, is still progressive in tlie
inflamed state of the part, and is the more rapid because of the suspen-
sion or impairment of the proper conditions of nutrition. (2.) They are
due, also, to the penetration of the products of inflammation into the
very substance of the affected tissue ; not merely into the interstices of
its elemental structures, but into those structures themselveB. These
two methods of change are not essentially connected ; but they ait
generally, in various proportions, coincident and mutually influential;
and when concurring it is hardly possible to assign to each its share in
the result to which they lead.
One of the most common effects of inflammation in an organ is a more
or less speedy softening of its substance ; and this is due not only to
infiltration of it with fluid, but to a proper loss of consistency, a change
approaching to liquefaction, or to disintegration, of which, indeed, it ia
often the first stage. Of such softening, some of the best examples
are in the true inflammatory softening of the brain and spinal cord, in
which the softened part is usually found to consist of broken-up nervous
substance, together with more or less abundant granular products of
inflammation. Such softening also may be found in the lungs: the
peculiar brittleness and rottenness of texture, which exist with the other
characters of hepatization, are evidently due to changes in the proper
tissue, more than to incorporation of the products of inflammation. In
staphyloma of the cornea, similar softening ensues in connexion with the
opacity and other changes of appearance. But, perhaps, the most
striking instance of softening in inflammation (and it is the more so
because the softening probably precedes the otlier evident signs of in-
flammation*) is to be found in bones. One may generally notice that an
acutely inflamed bone is soft, so that a knife will easily penetrate it
Thus it may be found in the phalanges of the fingers when they partake
in deep-seated inflammation, and thus, sometimes, in the neighborhood of
diseased joints. The change depends partly on an absorption of the
earthy matter of the bone, this constituent being removed more quickly,
and in greater proportion, than the animal matter ;t but the entire
material of the bone is softened.
• See KQss, as quoted hy Virchow, in liis Archiv, i. p. 121.
t Gendrin, Hi.>t. dcs Innauiinatiuns, i. p. 383.
BOFTBNINa OF INFLAMED PARTS.
259
Fig. S».»
The Boftenmg of bonefl maj permit peculiar subsequent changes,
especially their swelling and expan-
sion. Thus in a remarkable case
commnnicated by Mr. Amott to Mr.
Stanley, after excision of the bones
of an elbow joint, inflammation en-
sued in the shaft of the humerus,
ind after four months the patient
died. The end of the humerus was
doD-red, and swollen, with expansion
or separation of the layers of its
wiDs (fig. 89). And the case showed
weD llie coincidence of absorption
and of enlargement by expansion;
for though the inflamed humerus was
thus enlarged and contained more
blood than the healthy one, '^ yet it
was found not to weigh so much by
half."
Similar expansions of bone, with
all the characters of inflammation,
A O B
and such as could not have happened
without previous softening of the tissues, form part of the many swollen
and enlarged bones which are common in all museums.f Doubtless, in
many of these cases, the disease has been of very slow progress, and the
separation of the seyeral layers of the compact bone, which the speci-
mens display, must be ascribed to their gradually altered form, as they
have grown about the enlarging bloodvessels and interlaminar inflamma-
tory deposits. But, in other cases, the expansion has in all probability
been more rapid, the softened bone yielding and extending, as the
naturally softer tissues do, in an inflammatory swelling.
The characters of a bone thus expanded are easily discerned. Its
substance may be irregularly cancellous or porous ; but the most striking
change is a more or less extensive and wide separation of the concentric
laminse of the walls of the bone, so that, as in the section of the femur
(fig. 40), the longitudinal section of the enlarged wall appears composed
of two or more layers of compact tissue, with a widely cancellous tissue
between them : and these layers may sometimes be traced into conti-
nuity with those forming the healthy portion of the wall. Usually, the
separated layers are carried outwards, and the bone appears outwardly
• A, the inflamed humerus. The swelling of its lower part is shown by contrast with
that of the corresponding part of the healthy humerus b. The separation of laminae is
slMiwn in C: all the figures are reduced one half From Mr. Stanley's Illustrations^ pi. i.
fip^. 4, 5, 6.
+ In the college Museum, Nos. 593 to 600, and 3086 to 3094 ; and in the Museum of St.
Banholomew's, Series L Nos. 56, 94, 138, 196, 197, 198, &c.
260 SOFTEHINO OF INFLAXKD PABT8.
enlarged ; but sometimea the inner laycre of the wall are pressed inirardi,
and encroach upon the medullary tissue. In the first periods of the
disease, the cnncellons tissue betYen
the separated layers of the Tall hu <
wide spaces, which are usually filled
with a blood-colored medulla : but tbii
tissue, like the often coincident extern^
formations of new bone, appears to
have a tendency to become solid and
hard ; and its fibrils and laminie may
thicken till they coalesce into a com-
pact ivory-like substance, harder than
the healthy bone.
Again, For examples of softening ii
inflammation, I may adduce the soften-
ing of ligaments, such as pemitB that
great yielding of them which we ahnort
always see in cases of severely inflam«i
joints. This is not from mere defefr
tive nutrition ; for it does not happen
in the same form, or time, or meamiCi
in cases of paralysis or paraplegia en-
gendering extreme emaciation. Neitkr
is it from the soaking of the ligament!
with the fluid products of the inflam-
mation ; for it does not happen in
the abundant effusions of the slighter inflammations of the joints ; vA
when ligaments are long macerated in water they yet retain nearly iD
their inextensibility. It appears to be a peculiar softening, or diminished
cohesion, of the proper tissue of the ligaments : the result of a degene-
ration, combined with infiltration of inflammatory products.
We may see such changes in the ligaments of all joints ; in the hip,
in the cases of spontaneous dislocation occasionally seen, independent of
suppuration or ulceration of the parts belonging to the joint ; in d»
wrist, when the ulna after disease becomes so prominent ; in the vertehr«,
especially in the ligaments of the atlas and axis. But we see the effect!
of this softening best in diseased knee-joints and elbow-joints ; and in all
these casea we may often observe an interesting later change when the
inflammation passes by. The ligaments, softened during the inflamma-
tion, yield to the weight of the limb, or more rarely, to a musculsr
force, and the joint is distorted. Then, if the inflammation submdes,
and the normal method of nutrition in the joint is restored, the elongated
ligaments recover their toughness, or are even indurated by the organi-
zation and contraction of the inflammatory products deposited in them.
" From a upeciinen in the Muteunt of Si. Bartholomew'a, Serial i. No. M.
IN9BR8TITIAL ABSORPTION OF INFLAMED PARTS. 261
But they do not recover their due position ; and thus the joint is stiffened
in the distortion to which its ligaments had yielded in the former period
of inflammation. In the crowds of stiff, distorted, and yet not immovably
Sied joints, that one sees as the consequences of inflammation, these
dimges must generally have happened to the ligaments : first softening
tnd yielding ; then recovery, with induration, and perhaps some con-
tnetion, due to their atrophy and the organization of the inflammatory
deposit The cases are aggravated by similar changes in the adjacent
parts; for the stifihess of* such joints is not due to the ligaments alone ;
all the subcutaneous tissues are apt to be adherent and indurated.
The ABSORPTION of the affected tissues is another example of the
deatmctive changes ensuing in the inflammatory process. Like the
degenerations, which, probably, always precede it, it is, in many inflam-
mttoiy conditions, a peculiarly rapid event ; and it may affect, at once,
the proper elements of a part, its bloodvessels, and the inflammatory
products that may have been previously deposited among them.
I shall refer here only to that which has been called interstitial <U>$orjh
tm; to the removal of parts from within the very substance of the
tiaBueS) as distinguished from the removal by the ejection of particles from
die surface, of which I shall afterwards speak as occurring in ulcenxtion.
Interstitial absorption of inflamed parts in seen very well in inflamed
bones. The head of a bone may be scarcely enlarged, while its interior
11 hollowed out by an abscess ; what remains of the bone may be indu-
nted, as by slight and tardy inflammation, but so much of the bone as
waui where now the abscess is, must have been inflamed and absorbed.
!Die changes in the instance of abscess in the lower end of the tibia are
irell shown in fig. 41, page 262.'*' Here too, the evidence of absorption
is completed by the similar excavations formed in bones within which
^ysts and tumors grow; for in these cases no other removal than by
ibsorption seems possible.
To similar absorption of inflamed tissue we may refer the wasting that
ire notice in the heads of bones that have been the seat of chronic rheu-
matism. The best examples of this are in the head and neck of the femur ;
ftnd the retention of the compact layer of bone, covering in the wasted
cancellous tissue of the shortened neck and flattened head, is characte-
risdc of interstitial absorption, as distinguished from ulceration, by which
the cameellous tissue is commonly exposed. In these cases of chronic
inflammation of the bones, we may notice, also, an appearance of dege-
neration that precedes a peculiar mode of absorption or of ulceration.
While the articular cartilages arc passing through the stages of fibrous
degeneration, and are being gradually removed, the subjacent bone is as-
raming the peculiar hardness which has been termed ^^ ebumation," or
" porcellaneous" change. Now this change is effected by the formation of
* Museum of St Bartholomew's, Ser. i. No. 82.
36S IITTBBSTITIAL ABSORPTIOK OF tVFLAMBD PABTl \
very imperfect bone ; of bone that has no well-formed corpnsclea ; mi'i ^
resemblea the result of mere calcareona degeneration rather tbu i '
genuine ossifying induration. And its character as a degeneration il
further declared in this, that it is prone to destructive perforating ulce-
ration, which often gives a peculiar worm-eaten appearance to the bonei
thus diseased.*
With these changes in rheumatic bones we may also cite, as instancd
of absorption during slow inflammation, the changes which Mr, GrulliTeif
first described as apt to ensue after injuries about the trochanter of tbe
femur (fig. 42). In such cases, without any appearance of ulceratin
destruction, the bead and neck of the femur may waste by absorption,
the neck becoming Bhortcned and the head assuming a peculiar conidl
form. We might regard these effects as simple atrophy, if it were not
that they are like the effects of the more manifest inflammation in the
* A cbange, which appears u> correB[xiiul with the eburnalion of bone, is deacribed bf
Mr, Tomes, as occuTrini; in a pan or a toolli whicti lte> beneath h carious cavity. In ball
oases, the inJuralion rnighl euKgcst that it is calculalcd lo relarcl the progreu of the disease,
but we have no evidence that it does this it) an effective manner; and in the case of the
bones there is every appearance thai the destruction is most rapid where there is most indn-
t Edinburgh Med, and Surg. Journal, vol, ilvi. His illustration of a well-marked case 'u
liore copied. — The change is illuslraled in No. 3313 in the College Museum.
OPENING OF ABSCESSES. 268
kcnmatic cases, and that the existence of inflammation during life is often
bdared hj the abiding pain and other symptoms following the injury.
Again, other examples of the absorption of inflamed parts, or of parts
hat have been inflamed, are presented in the wasting of glands after in-
hmmation ; as in cirrhosis of the liver, in some forms of granular dege-
Mrations of the kidney, in the indurated and contracted lung after
pienmonia.
No doubt, in these cases, the reduction of the organ depends, in a
netsure, on the contraction of the difiiised inflammatory product, as it
vginizes ; but in many cases the quantity of new tissue is extremely
■Dili (it is so in the shrivelled granular kidney) ; and, in all the cases, we
Bfty well doubt whether the contraction of organizing lymph would pro-
daee sach extensive and uniform absorption of the proper substance of
m organ, if there were not a previous condition favoring the absorption.
The most probable explanation of these cases seems to be, that as, in
the early periods of inflammation, the softening and the degeneration of
the inflamed tissues coincide with the production of the lymph ; so, as the
iDflammation subsides, and subsequently, the absorption of the degene-
nted tissues may often coincide with the full organization and contrac-
tioD of the lymph. And it is altogether most probable that these events
are independent though concurrent ; and that each occurs as of itself, not
m the cause or consequence of the others.
To all these cases must be added the fact of the absorption of the
Uoodvessels, and other necessary apparatus, of the inflamed tissues. The
aksorption of the absorbents themselves must coincide with that of the
tinoes. What a problem is here ! These, that have once been the appa-
ntiis of maintaining life, that had been adjusted to its energy and
Uiion, now, as it fails, remove themselves in adaptation to its failure.
How can this be ? We can only guess that its method is just the reverse
cf the method of formation ; that, as in growth the bloodvessels and
lymphatics follow in the course of evolution of the growing parts, open-
iog and extending into each new part as it forms, so, in decrease, they
Mknr, and closing in harmoniously with the general involution, mingle
ih»r degenerate materials with those of the tissue, and are absorbed by
die nearest remaining streams of blood.
Once more ; not only the original elements of the tissues may be ab-
•orbed, but, even more rapidly, the new-formed products of inflammation.
We have the best example of this, as well as, indeed, of many of the facts
vUeh I have been mentioning, in the spontaneous opening of a common
ilncesB ; which, though it be so common a thing, I will venture to de-
icribe here.
Let us suppose the case of an abscess formed in the subcutaneous tis-
Re ; of such an one as I described some pages back, and may illustrate
tj the following sketch of an imaginary section through its cavity and the
loper jaoent skin (fig. 43). It has had its origin in lymph infiltrated tlirough
264 ABSOBPTION OF IKFLAHBD FARtB.
a certain area of the tisanes, and forming themn a hard, drcnmBcribed,
inflamed mase. Of tbia lymph all the central portion is sappnrated, ui
forma the purulent contents of the abscess ; vhile the peripheral put
acquires more abundant bloodvessels, assumes the character of a gn-
nnlation layer on its surface, and forms the proper vail of the abscen.
The pus of such an ahacess aa this will contain probably, besidea ttt
proper constituents, some of the disiDtcgrated tieeue of the part in whidi
it has itfl seat. We cannot, indeed, be quite sure of thia ; for it may bei
that while the lymph is being formed, or being converted into pus, thfl
proper tissue of the infiltrated part is undcrgoiug absorption ; and al-
though, in the pus of abscesses thus formed, we of^en find abundant
molecular and granular matter, yet this may be the debris, not of the
tissue, but of the ceils or fibrine of the inflammatory product. We
cannot, I think, he sure on this matter : but we may be aure that one of
these two events occura : that the circumscribed portion of the tissue, ii
which such an abscess has its seat, degenerates ; and is then either ab-
sorbed, or else disintegrated, so as to mingle more or less of its eubatanot
with the pus.
The abscess thus formed has a natural tendency to open, unless all tbs
inflammation in which it had its origin subsides. Inflammation appean
to be not only conducive, but essential, to the Bpontancous opening of
abscesses ; for where it is absent, the matter of chronic abscesses viD
remain, like the contents of any cyst, quiet for weeks, or months, or
years ; and when in chronic abscesses or in cysts, inflammation ensiM
through the whole thickness of their coverings, it ia usually certain that
their opening ia near at hand, Thia difference between acute and ohro*
nic abscesses makes it very doubtful whether tlie inflammation of tho
ooverJDgs of an abscess can bo ascribed to any local influence of tlw
pus. But to whatever it may be ascribed, we may refer to this inflam-
mation, and to the degenerative changes that accompany it, the com-
OPBHIN0 OF ABSCESSBS. 205
quick absorption of the integuments, and of the infiltrated
T the collection of pus : and thus the fact, however we may
* it, that the integuments are more prone to inflanmiation, and
Aj engaged in it, than the other tissues about an abscess are,
sed to explain the progress of matter towards the surface,
bough this, I think, is much less probable) the tissues and the
ween an abscess and the surface may, after the degeneration
»mpanies the inflammation, be disintegrated, and may mingle
niles with the purulent contents of the abscess. But, in favor
ef that they are absorbed, we have the evidence of analogy ;
) same thinning and removal of integuments takes place when
le over a chronic abscess with a thick impenetrable cyst, or
cysted or even a solid tumor. In these cases, absorption alone
; and the cases are so similar to the ordinary progress of
:hat I think we may assign all the changes of the integuments
to the same interstitial absorption.
or preparatory to their absorption, the integuments over an
wme softer and more yielding. The change is, most probably,
I softening as I have described in degenerating inflamed parts.
aoe especially in the portion of the integuments over the mid-
r the most dependent part, of the abscess ; and this most soft-
m, yielding most to the pressure of the pus, becomes prominent
i parts around it, and points. Mr. Hunter refers to this as
dng or elongating process." He says: ^^ Besides these two
omoving whole parts, acting singly or together [that is, besides
Eitial and the progressive absorption], .there is an operation
dnct from either, and this is a relaxing and elongating process
between the abscess and the skin, and at those parts only where
begins to point. It is possible that this relaxing, elongating,
Ing process, may arise in some degree from the absorption of
»r parts ; but there is certainly something more, for the skin
B an abscess is always looser than a part that gives way from
lanical distension, excepting the increase of the abscess is very
[Htrts relax or elongate without mechanical force, but from par-
tnuli, is evident in the female parts of generation, before the
e foetus ; they become relaxed prior to any pressure. The old
ike country can tell when a hen is going to lay, from the parts
loose about the anus."'*'
Iiese changes of degeneration, leading to softening and absorp-
nsuing in the cutis and the lymph over such an abscess as I
tibed, we commonly notice that the cuticle separates, leaving
Blood, Sec. Works, vol. iii. p. 477. The Inst fact is, probably, not appropriately
change in the state of parts before the birth is most likely duo to relaxation of
; raotCQlar fibres that they all contain.
266 DEGENERATIONS. OF INFLAMED TISSUBB.
the Yory point, or most prominent part, of the abscess bare (fig. 43).
The cuticle is sometimes raised as in sHblister ; but much more often it
cracks and separates, and then, with its broken edges raised, peels off
like dead cuticle : and we may believe that it is dead, partaking in the
failure of nutrition in which all the parts over the abscess are iuTohed,
and being removed as a dead, not as a merely degenerated, part.
At length, after extreme thinning of the integuments, they perish in
the centre of the most prominent part. Sometimes the perished part be-
comes dry and parchment-like, with a kind of dry gangrene ; but much
more commonly a very small ordinary slough is formed, and the detach-
ment of this gives issue to the purulent matter. The discharge is usually
followed by a more or less complete cessation of the inflammation in the
integuments, and then the wall of the abscess, having the character of a
cavity lined with healthy granulation, heals.
The softening and absorption of inflamed tissues of which I have been
speaking, are the chief consequences, or attendants, of minuter molecular
changes, to which I must now refer. These changes are derived, as I
have already said, from one or both of two sources ; namely, the natural
degenerations of the inflamed tissues, and their penetration by the in-
flammatory product.
The rapid softening of an inflamed tissue is, probably, in most caseSy
dependent on both these conditions ; and yet in some cases, and in some
measure in all, it may be ascribed to a simple degeneration, such as might
be classed with those named liquefactive. Thus, in the case of the in-
tegimients over an abscess, we find it associated with infiltration of de-
generating lymph-products, and probably in some measure due to their
presence ; but in the brain and spinal cord, the softenings of inflammar
tion are, in structure, and probably also in nature, very like those of
mere atrophy. .
Less rapid softening is often connected vnth a well-marked fatty de-
generation of the inflamed tissues. This is especially the case in the
muscles, bones, cartilages, cornea, and certain glands, as the liver and
kidney.
I found such a degeneration well-marked in the fibres of the heart of
a man, who thrust a needle through his left ventricle four days before
his death. There were evident signs of pericarditis, and of inflamma-
tion of the portion of the heart close by the wound ; and both in this
portion, and, in a less degree, in all other parts of the heart, I found
such a fatty degeneration of the muscular fibres as I could not have
distinguished from that which occurs in the corresponding atrophous
degeneration.* The same changes may be oftener observed at later
* I spoke with some hesitation about this case when the lecture was given ; for I could
scarcely believe in the occurrence of such an acute degeneration. The admirable observB'
tions of Virchow (Archiv, B. iv. H. i.) leave no doubt that such a change is a general atten-
BEGEKBRATIONS OF INFLAMED TISSUES. 267
periods after inflammation of the substance of the heart ; and in some
ef these cases the interstitial deposits of lymph arc organized into fibrous
tiame, irhile the muscular fibres themselyes are degenerate. The ex-
tended observations of Virchow, on the inflammations of muscles,^ show
Aat such fatty degeneration of the fibres usually occurs in nearly all but
the most acute cases ; in these, softening and disintegration of the mus-
cdIbt fibrils rapidly ensue, and fatty particles appear subsequently, if at
an, in the inflammatory exudation and disintegrated tissue that are min-
f^ed within the sarcolemma. He shows, also, very clearly, how the
dimnges in the muscular fibres may be associated with the efiiects of
lymph deposited interstitially among them, as well as within them, and
ptflBing through its ordinary progress of development or degeneration ;
ind that they may be followed by the complete wasting, or absorption,
of the degenerate tissue, in the place of which the new fibrous tissue
formed by the developed lymph may remain like a scar or a tendinous
^lOt.
In inflamed bone, also, Virchow has traced fatty degeneration as a
part of the process of softening which precedes its expansion or absorp-
tion. The change is observed not constantly, yet very often, as a fatty
degeneration of the bone-corpuscles, in the interior of which small fatty
molecules appear. After, or sometimes without, such previous changes
in the corpuscles, he has also traced their enlargement and the gradual
softening, disintegration, and final liquefaction and separation of the
proper bone-substance, immediately surrounding and including each cor-
puscle. The changes he has thus traced accord completely with those
described by Goodsir and Redfem in the cartilage; and, as he well
observes, they have peculiar interest in relation to the occurrence of
fiitty degeneration, as a part of the inflammatory process, inasmuch as they
are the results of the same process as that by which, normally, the me-
dullary spaces and areolse of growing bone are formed, by which, as the
bone grows, the compact cortical tissue is gradually changed into areolar
or spongy tissue, and by which the peculiar "mollities ossium," or "osteo-
malacia," is produced.
Changes like these in inflamed bone have been found in ulcerating and
articular cartilage ; and they are here the more important, as showing
a process essentially similar to the degeneration of inflammation, although
occurring in a tissue that has no bloodvessels, and into which we have no
evidence of the penetration of lymph. They have been chiefly observed
by Dr. Redfem ;f but have been confirmed by many. They consist,
mtially, in the enlargement of the cartilage-cells, with increase of the
duit of inflammation of muscles. Few things could be more assuring than to find the
opinions I expressed concerning this and other parts of the inflanmiatory process completely
eoofiimed by him.
* In his Essay on Parenchymatous Inflammation, cited above, p. 266.
t Anormal Nutrition in Articular Cartilages: Edinburgh, 1850. And '^On the Healing
of Wounds in Articular Cartilages/' in the Monthly Journal of Medical Science, Sept 1851.
268 DEGENERATION OF INFLAMED TIBSUia.
nuclei, or of peculiar corpuscles contained in them, or with fatty degene-
ration of their contents, and fading, or similar degeneration of tkdr
nuclei. The hyaline intercellular substance at the same time splits up,
and softens into a gelatinous and finely molecular and dotted substance,
or else is gradually transformed in the less acute cases, into a more or
less fibrous tissue. The enlarged cartilage-cells on the surface are re-
leased, and may discharge their contents on the surface of the ulcer;
and the intercellular substance is gradually disintegrated and umilarlj
discharged, or, whatever part of it remains, is transformed into fibrmv
tissue, and becomes the scar by which the ulceration is, in a measure,
healed.
Lastly, in the cornea, a series of observations on the eSects of inflaoi-
mation, purposely excited in it by various stimuli, '^^ have shown that the
changes in it are not due to any free exudation of lymph in it, but to
alteration in its proper constituent textures. They consist, chiefly, ia
swelling and enlargement of its corpuscles, the appearance of minute
fatty molecules in them, and the iucrease and enlargement of their nu-
clei. The intercellular substance becomes, at the same time, tarUd,
more opaque, denser, more fibrous, and, sometimes, finely granulated;
and in some cases fatty molecules appear in it. The changes thus pro-
duced in the cornea are not essentially difierent from those that foUow
its idiopathic inflammations ; and, as Yirchow concludes, they are ex-
tremely like those of the arcus senilis.
Now, from all these cases, with which others of similar import might
be combined, we may conclude that the degeneration of the proper tis-
sues of inflamed parts, which we recognise in the mass as a softening of
their substance, or an aptness to be absorbed, is, very often, essentially
like the fatty degeneration which we have studied as a form of atrophy
of the same parts ; that the changes of structure are, in both, essentially
the same; difiering in rate of progress, but not in method or result
And the cases of the bones, cartilages, and cornea, are the more to be
considered, because the changes described in them cannot be referred, in
any considerable measure, if at all, to a process of exudation into the
elements of their tissues.
The fatty degeneration and that of softening, as by progressive lique-
faction, are, doubtless, the most general forms in which the defective
nutrition in an inflamed part is manifested. But something allied to the
calcareous degeneration occurs in the ossifications of the laryngeal
cartilages when they are involved in inflammation, and of such other
cartilages as are prone to an imperfect ossification in old age. These
are frequent events ; and as Virchow observes, the ossification occurs
• They are published briefly in Virchow's essay already cited ; and in detail in a disM^
tation — " Der nonnale Ban der Cornea und die pathnlogischen Abweichungen in derasel*
ben,' WOrzburg, 1851 — by Fr. Strube, by whom the observations were made under the
superintendence of Virchow.
DEGENERATIOXS OP INFLAMED PARTS. 269
constantly and often exclusively in the very part of the cartilages which
torrespondB with the seat of the inflammation. To the same class of
eMes we may refer the ossifications of parts of the articular cartilages in
dironic rheumatic arthritis (p. 287), and the formation of the imperfect
dflntme or osteo-dentine which ensues in inflammatory afiiBctions of the
tootb-pnip, or in the pulp of the elephant's tusk round bullets lodged in
it In all these cases, it may be observed, the inflammatory process is
ittended with such changes as occur almost normally at some later period
of life, or in old age ; such changes, then occurring, are reckoned among
tke natmtil degenerations, the signs of simply defective formative power:
Ae difference, therefore, between the natural degeneration and that of
the inflammatory process seems to be one of time more than of kind ; the
inflammatory is premature and comparatively rapid, and ensues with
tlie characters of disturbed, rather than of merely defective, nutrition.
Sueh are some of the evidences of degeneration ensuing in the proper
tiBBiies of inflamed parts. The cases I have selected are of the simplest
loiid ; whose results are least confused by the changes that may ensue in
Ijmph penetrating the degenerating tissue. When this happens, it is
perhaps impossible, at present, to separate the two series of changes :
(boBej I mean, which are due to the degeneration of the elements of the
tiiBne, and those which are occurring in the lymph within them. The
mtter are especially described by Yirchow, in the muscular fibres, and
n the renal cells, in what he calls the parenchymatons form of
pwiiilar degeneration of the kidney. In the latter he says,**" that
fhile, as in the croupous form, fibrinous cylinders of free inflamma-
arj exudation may be found in the straight, and a part of the convo-
iited tubes, other changes are ensuing in the epithelial cells ; and by
iiese chiefly, and sometimes alone, the characteristic altered structure
if the kidney is induced. They occur especially in those parts of the
nbee which run transversely or obliquely. In the first stage of the
liseue these cells enlarge, and their molecular nitrogenous contents
nerease, by the penetration of the inflammatory product into them. In
he second stage, the increase is such that the cells break up, and the
irine-tubes appear filled with fi molecular albuminous substance ; or else
he fatty transformation ensues in them, and they are filled with finely
granular fatty matter, and appear as granule-cells, or granule-masses.
In the third stage the fat granules depart, and an emulsive fluid is
"onned which may be absorbed or discharged with the urine.
Yirchow describes similar changes in the hepatic cells : but it may
mffice only to refer to these. What has been already described will be
OLOiigh, I hope, to justify the expressions used at the beginning of the
eoture : namely, that the changes (short of death) which ensue in the
* In his essay, referred to at p. 320. Many of his facts were published by one of his
pupils, Dr. Niemann, in his dissertation, De inflammatione renum parenchymatosa, BeroL
1848.
270 ULCERATION.
proper elements of an inflamed part are twofold: first, those of a
degeneration, such as might ensue in simply defectiye or suspended
nutrition ; and secondly, those which depend on the penetration of the
exuded inflammatory product. Either of these may, perhaps, oecor
alone, but the first can be rarely, if ever, absent. When they are o(Hh
current, their several effects cannot be clearly separated ; and when tbj
both take place rapidly, the degeneration is apt to lose all likeness to
such as naturally occur, and to appear as only contributing to the r^nd
disintegration and Uquefaction of both the tissue and the inflammatory
product. This appears to be the case in many instances of ulceratioo; *
a process which I have deferred to the very end of the history of inflam-
mation, because all the other parts of the disease appear to be engaged
in it.
I need hardly say that, ever since Hunter's time, confusion has
existed in the use of the terms employed for various kinds or methods of
absorption and ulceration. Of all that Hunter wrote, nothing, I think,
is so intricate, so difficult to understand, as his chapter on ulcerativo
inflammation ; and much of the obscurity in which he left the sabjeok
remains. Some of this depends on the same terms having been used ii
different senses, and may be avoided if it is agreed to speak of tho
removal of those particles of inflamed parts, which are not on an open or
exposed surface, as the '^ interstitial absorption" of inflamed partfli
Then, the term "ulceration** may be employed to express the removal of
the superficial or exposed particles of inflamed parts : or, rather, when
the epitheliimi or epidermis of an inflamed part is alone removed, it may
be called "abrasion** or " excoriation ;** and when any of the vascular
or proper tissue is removed from the surface, it may be called " ulcere
tion.** If, in such ulceration, the superficial particles may be supposed
to be absorbed, the process of removing them may be termed " ulcere
tive absorption ;** but if, as is more probable, their removal is effected
entirely by ejecting them from the surface of the inflamed part, then tho
term " ulceration*' may sufficiently express this ejection, and will stand in
stronger contrast to the " interstitial absorption** of the particles that are
not so ejected, but are taken into the blood.
I have lately referred to the uncertainty whether, as the cavity of an
abscess enlarges or opens, the tissues, and the infiltrated lymph, that are
removed from the inner surface of its boundary walls, are absorbed, or
are disintegrated and mingled with its fluid contents ; in other words,
whether they are absorbed or ejected. The same uncertainty exists, in
some measure, in the case of ulceration, concerning which, indeed, all
that was said (p. 264), respecting the necessity of inflammation to the
opening of abscesses, might be here repeated, inasmuch as inflammation
seems essential, not only to the formation, but to the extension or en-
largement, of an ulcer. The ulcerative process cannot take place in
ULCERATION. 271
17 tisBiie ; previous degeneration of the tissue, and that such as
tin the inflammatory process, is a condition essential to it.
;, when this condition is provided, is the enlargement of an ulcer
i hj absorption of its boundaries, or by the gradual detachment
tfting off of particles from their free surface ? Both methods of
ement may, perhaps, in some cases, ensue ; but the probabilities
&ror of the enlargement being, as a general rule, effected by the
1 of particles.
1:— 1. Parts to be removed from a surface are generally cast off
jian absorbed, as cuticles of all kinds arc, and the materials of
08 ; so that, by analogy, wo might assume that the particles of
ice of a spreading ulcer would also be cast off.
le materials of the ulcerating tissue may be sometimes found in
large from the ulcer. In most cases, indeed, this is impossible ;
iiaps it is so only because, when the tissues, and the lymph
1 in them, are degenerate, and broken up, or decomposed and
I, we have no tests by which to recognise them. In the ulcera-
uiilage, however, in which inflammatory exudation has no share,
ess of ejection of the disintegrated tissue is clearly traced; and
t deem this almost a proof of the same process being observed in
laes, if it were not that in the cartilage a necessary condition of
in, the presence of a circulation, is wanting. The same process
on, however, is traceable in ulcerating bone, where absorption
cur. It is shown by the observations which I have quoted from
; and Mr. Bransby Cooper has observed that, while in pus from
tfl only traces of phosphate of lime are found, the pus from
liseased bone contains in solution nearly 2^ per cent.* A
bnt less complete, observation had been made by Mr. Thomas
• and by v. Bibra; J and we may believe that at least some of
phate of lime, in these cases, was derived from the diseased
strengthens this belief to observe, that, in many cases small
•1 Gaxeue, May, 1845.
f : Tremtiae on Diseases of the Bones, p. 89.
■cbe Untersucbungen verschiedener Eitemrten, p. 85.
icfief may seem the more reasonable, because of the similar fact of the quick
of booe-earths in inflamed but not ulcerating bones. Still, it must be admitted,
noe is needed that the quantity of bone-earths discharged with the pus is pro-
or equal to the quantity lost by the ulcerating bone. For if what has been said
fthe conformity of the properties of inflammatory and reparative products with
• tissues from which they are produced, be true, then will also pus from diseased
■■ more bone-earths than pus from any other tissue, even though the bone be not
Gimnnlations upon bone doubtless contain more bone-earths tlian those on sod
llbgy may ossify : now the relation of pus to granulations is commonly that of
■f oelb 10 the like cells developing ; therefore we might expect that pus from
gnnralBtiont from bone, will contain a large proportion of bone-earths, indepen-
ly be derived from the ulceration of the bone.
^
272 ULCERATION.
fragments of bone and other tissues are detached, and cast out vith tb
fluid from the ulcerating part. These, indeed, when they are not b^^
ments of tissue detached by ulceration extending around them, are giii
examples of the transition that may be traced from ulceration to sloeghiH
or gangrene of parts, between which, if ulceration be alwaya acoompGiM
by ejection, the only essential difference will be one of degree; the
tion being a death and casting off of invisible particles of a tiasiie,
gangrene implies the death and casting off of visible portions.
4. And it may be proved of many that wo call ulcers, that they bcgp
as sloughs which are cast off, and leave the ulcerated surface benwik
We may often sec this, on a large scale, in the instances of what
called sloughing ulcers ; but Dr. Baly has proved it for a much
range of cases, in his observations on djrsentery, in which he has traeil
how even the smallest and the most superficial ulcers of the intestine MH
preceded by the death and detachment of portions of the mucous iiM»
brane, with its covering of basement-membrane and epithelium.*
From these considerations, wo may hold it as probable that uIcentiM
is, usually, the result of the detachment of dead portions or molecoleirf \
an inflamed tissue, and that the substance removed in the process if nl
absorbed but ejected. There are, indeed, some cases which may mske m
unwilling to admit, at present, that all ulceration is by ejection ; sueb ai
those of bone ulcerating under cartilage, or in the rapid eztensioB «f
inflammation within it, or such as the spreading ulceration of the verl^
brse, or of the heads of bones, that is not attended with external dischirgi
of flui<l. These may, for the present, interfere with the universality df
the rule, but not with its generality.
But, if we may believe that the removal of a tissue by ulceration ii
generally effected by ejection of its substance, the question msj bt
asked, in what form is it ejected ? Dr. Buly's observations enable u to
say that, in the first instance, a visible slough is detached, a portion df
the tissue dying and being disconnected from the adjacent living tioaa
But, after this is done, when an ulcer enlarges, or extends and spreidi,
is the material of the tissue still removed in visible sloughs or fragmenti!
Certainly it is so sometimes ; for we may find little fragments of bone ii
the discliarge from ulcerating bone, especially in strumous ulceration.
But in other cases we have no evidence of this kind ; we cannot detect
even microscopic fragments of tissues in the disdiarges, and we lasA
suppose that they are removed, in a state of solution or of molecoltf
division, in the discharge from the diseased part.
To speak of the solution of tissues in the discharges of ulcers mij
seem like the revival of an old error long since disproved. But thou^
the expression may be revived, it is with a new meaning. The proof
has, truly, been long completed, that healthy tissues, even though th^
be dead, cannot be dissolved in pus, or any such discharge; but the
* Gulitonian Lectures: Medical Gazette, 1847.
ULCERATION. 278
that bound or form the walls of a spreading ulcer are not healthy ;
ij are inflamed, and, as I have been just saying, their elements, and
»prodact8 of inflammation in and among them, are degenerate, so that
ff may be now minutely divided, or even soluble in fluids that could
i diflBolve them while they were sound. Insolubility is as great an
tede to absorption as to ejection in discharges; no tissue can be
lorbed without being first so far changed as to be soluble in fluids
di which it was before in contact and unharmed. Therefore, whether
\ hold the ordinary spreading of an ulcer to be by absorption of its
andaries, or ascribe it to their ejection, we must, in either case, admit
It they are first made soluble. And if this be admitted, then it is
dK consistent with analogy, and most probable, that the extension of
i aker, independently of sloughing, is accomplished by the gradual
feneration of the tissues that form its walls, and by their being either
■ntegrated and cast off* in minute molecular matter, or else dissolved
d ejected in solution in the discharges from the ulcer.
The solution here spoken of is such as may be effected by the fluid
wharged from any spreading ulcers ; but we may doubt whether all
leharges from ulcers possess a corroding property, such as Rokitansky
miB to ascribe to them, and such as he considers to be the chief cause
the extension of all ulcers. We may doubt, I say, whether all ulcera-
a can be described as a corrosion or erosion of the tissues by ichor ;
ty on the other side, we cannot well doubt that the properties of the
diarge from an ulcer, or a sloughing sore, may have a great influence
accelerating the degeneration and decomposition, and thereby the
ation, of the tissues that form its walls or boundaries. Many ichor-
B discharges from ulcers, inflame and excoriate the parts over which
ey flow, and thus inflaming them, they promote their degeneration, and
id them more readily to enter into the ulcerative process. Many such
leharges, also, are in an active state of decomposition ; and their con-
ct widi the inflamed tissues cannot but have some tendency to excite
mmposition in them ; a tendency which the tissues will be the less able
> resist, in the same proportion as they are already feebly maintaining
Mmselves, or as they have been moved by inflammation from their nor-
mI conditions, and their normal tenacity of composition.
On the whole, then, we may conclude, respecting the process of ulcera-
ioii, that its beginning is usually the detachment of a slough, or portion
r dead tissue, by the removal of the layer of living tissue that bounded
; that the spreading of an ulcer, independent of such visible sloughing,
effected by the inflamed tissues that bound it becoming degenerate,
d being detached in minute particles, or molecular matter, or being
imposed and dissolved in the fluid discharge or ichor ; and that this
reading may be accelerated by the influence of the discharge itself,
bich may inflame the healthy tissues that it rests on, and may exercise
decomposing ^'catalytic" action on those that are inflamed already.
18
274 H£ALIKO OF ULCERS.
I need hardly say that we have no knowledge by whioh to ezplam thi
peculiar and characteristic forms of certain ulcers. We seem whd^
without a guide to such knowledge ; but the existence of Buch speotte
forms is conclusive against the supposition that the extension of an nlw
is entirely due to corrosion by an exuded fluid. Such a fluid would ui
uniformly, unless the various efi^ects of disease on the tissues bounding
the ulcer should make them variously amenable to its influence.
«
We have as little knowledge of the nature and real difiSerences ol
the various fluids discharged from ulcerating surfaces, — ^the varioai
kinds of ichor* that they yield. They consist, generally, of fluid exudes
from the surface as an inflammatory product, and holding in suspensioi
or solution the disintegrated materials of the ulcerating tissue, and o:
the lymph infiltrated in them. The inflammatory product exuded on i
spreading ulcer has, indeed, the constituents of lymph or pus ; but the]
appear immature or degenerate, consisting of abundant molecuhu
matter, with flakes of soft, dotted fibrine, and ill-formed lymph- or pus
cells, floating in an excess of liquid. Such a substance is, probaUj]
always incapable of organization, both because of its own defect, tod
because of the inflamed state of the parts it is in contact with. Th
difiercnces that may, from the first, exist in the several examples of icha
are moreover quickly increased by the various chemical transfonnationi
that they undergo. Rokitansky alone has endeavored to enumerate tb
varieties of property that may hence issue, and the influences they ma;
exercise in the maintenance of the^diseasc.f
As from other inflammatory processes, so, from observation, we ma;
trace the transitions to the healing process. In the case of ulcerate
cartilage. Dr. Redfem's researches show that the healing is accomplishec
mainly, by the complete transformation of the remaining cartilage-sul
stance into fibrous tissue. Here is no proper process of exudation, fc
here are no interstitial bloodvessels ; the materials of the tissue itseL
by transformation, form the scar.
But in the vascular tissues, the reparative material is the lymph infi
trated in them at and near the boundaries of the ulcer. As the inflan
mation subsides (for here, as in other cases, the inflammation that pn
duced the lymph must cease for its development) the lymph passes throng
changes like those described in the abscess-wall, and the tissues in whio
it was infiltrated may, perhaps, recover from their degeneration. Pai
of the lymph, increased by fresh exudation, assumes the characters (
* I think it would be useful to employ the term ichor exclusively for those discbaifi
mixed with exudation thnt take place from ulcerating, t. r. from progressively ulceratiDit <
sloughing surfaces. For, altliough it may be oAen impossible to distinguish, by any mani/f
properties, such ichor from some of the thinner kinds of pus, yet, if the account of suppar
tion and of ulceration be true, a constant difference between pus and ichor will be, tht
the latter contains disintegrated niaterials of the ulcerating tibs^ue. the former does doC
f Pfttbologischo Anatomie, B. i. p. 213.
VATVRB AKB CAUSBB OF INFLAMMATIOK. 276
gnniilations, which, as we watch the progress of an improving ulcer,
mime daily more of the characters of those on healing open wounds.
We cannot, indeed, mark the very act, or tell the hour, at which the
inflammatory process was changed for the reparative ; at which the de-
generation ceased, and development began ; there are no hard boundary
lineB here, or in any passage from disease to health ; but the change is
gradually accomplished, and is manifest both in the organizing material
of the granulations, and in the pus which takes the place of the ichor,
ind exactly resembles that of the healing granulating wound. The ulcer
is no longer ulcerating, but healing; and the histories of the healing
doer, and of the healing wound, might be told in the same words.
LECTURE XVIII.
NATURB AND CAUSES OP INFLAMMATION.
Thb several parts of the inflammatory process have been now con-
lidered. They are — ^increased fulness of the bloodvessels, with retarded
movement of the blood ; swelling ; pain, or other morbid exalted sensa-
tion ; increased heat ; exudation of lymph from the bloodvessels ; defec-
tive nutrition of the proper elements of the affected part. The first five
•re often spoken of as the signs of inflammation, the last two as its effects ;
but these terms have reference only to the former being more transitory
phenomena than the latter : they are all, when they concur, constituent
parts of the disease; but the latter are less quickly recovered from
than the former.
It would not be judicious, I think, to refuse to call that process in-
flammation, in which any one of the conditions just enumerated is absent
or unobserved. Swelling, or pain, or much oftener, increased heat, may
be inappreciable in tissues that we may still rightly call inflamed, wliile
the other evidences of the disease are present. The same may be said
of increased or altered exudation from the bloodvessels. No such
exudation is observed in the diseased cornea or articular cartilages ; but
it would be unreasonable, in the case of an inflamed eye, to say that the
changes are due to inflammation in every part but the cornea ; and to
call the process leading to the ulceration or leucoma of the cornea by a
name different from that which we give to the coincident and similarly
excited process in the other tissues. So, during the inflammation of a
joint, it would be, at the least, inconvenient, to say that all the tissues
are inflamed except the softening or ulcerating cartilages. The pro-
greesive degeneration of tissue is, probably, never absent when the other
parta of the inflammatory process exist ; but, in quickly transitory cases,
it is often inappreciable. The altered state of the ciTCula^ioii mvj \^
276 NATURE AND CAUSES OF IKFLAKKATIOH*
unobserved : but it is, probably, always present ; for in the case of the
parts that have no interstitial bloodvessels, inflammation may still be
attended by enlargement of those of adjacent parts, on which their
ordinary nutrition depends.
The conclusion, then, may be, that in what may be regarded as well-
marked or typical examples of inflammation, all the characters I hiTe
enumerated are present as concurrent parts of the disease ; but that tbe
same name should not be refused to diseases in which any one of these
parts is absent or unobserved, especially when its absence may be ex-
plained, as in the case of inflamed cartilages, by some peculiarity of
tissue or other condition of the disease. I think it would not be right to
call any process inflammation in which there is neither an exudation of
lymph {i. e. of material capable of such developments or degeneration
as I have described), nor a deterioration of the proper tissue of the
affected part ; even though the other characters of the disease might he
present. But, really, whatever rule of nomenclature be adopted, ire
may expect to meet with many cases in which we shall doubt what name
to give to the processes which we watch, or of which we see the results.
There is neither here, nor in any other part of pathology, anything like
the unity, or circumscription, of species by which the zoologist, whose
nomenclature pathologists are prone to imitate, is justified in attaching
to each specific name the idea of several constant and unalterable charac-
ters in the beings to which it is assigned.
An examination of the very nature of the process of inflammation may
best be made in the form of a comparison of its effects with those of the
normal process of nutrition. And this comparison may be drawn with
two principal views; namely, to determine — 1st, how the effects of
inflammation differ, in respect of quantity, from those of the normal
process ; and 2d, how they differ from the same, in respect of quality or
method.
The decision on the first of these points may seem to be given in the
term "increased action," which is commonly used as synonymous with
inflammation. As used by Mr. Hunter, this term was meant to imply
that the small vessels of an inflamed part are more than naturally active,
in formation or absorption, or in both these processes. This is, probably,
the meaning still generally attached to the term by some; while, as
employed by those who believe the vessels are only accessories in the
work of nutrition, the expression " increased action '* may be used to
imply merely increased formation, or increased absorption. In either,
or in any, meaning, however, the term seems to involve the idea of an
increased exercise of vital forces, i. e. of those forces through the opera-
tion of which the various acts of organic formation are accomplished.
But, if "increased action** is to imply this, the description of the pro-
cess and effects of inflammation shows that the term cannot be properly
used, without some limit or qualification.
NATURS AND CAUSES OF IN FL A MM ATIOX. 277
If we consider the quantity of organic formation effected during tlie
■iaminatory process, in the proper substance of the inflamed part, it is
•ridently less than in health. All the changes described in the last
lecture are examples of diminished or suspended nutrition in the tissues
df the inflamed part : they are all characteristic of atrophy, degenera-
tion, or death. The tissues become soft, or quite disorganized ; they are
relaxed and weakened ; they degenerate, and remain lowered at once in
itnicture, chemical composition, and functional power; or else, after
feneration, they are absorbed, or are disintegrated, or dissolved, and
cut out ; they die in particles or in the mass. During all the process of
inflammation, there is no such thing as an increased formation of the
Bitural structures of tlie inflamed part ; they are not even maintained ;
Aeir nutrition is always impaired, or quite suspended. It is only after
the inflammation has ceased that there is an increased formation in some
of the lowly organized tissues, as the bones and cellular tissue.
So far, then, as the proper substance of the inflamed part is con-
eemed, there appears to be decreased action ; that is, decreased forma-
tion. There may be, indeed, an increased absorption ; but this is also,
in one sense, characteristic of decreased exercise of vital force ; since all
absorption implies a previous degeneration of the part absorbed. Nor
can we justly call this, in any sense, ^' increased action," till we can show
how absorption is an action of vessels.
Thus far, one of the constituents of the inflammatory process, one of
the characters in which it differs, in respect of quantity, from normal
nntrition, is a defect in the nutrition of the proper substance of the
infltmed part.
Bat it is characteristic of the complete process of inflammation, that,
while the inflamed structure itself suffers deterioration, there is a produc-
tion of material which may be peculiarly organized. Here, therefore,
miy be an evidence of increased formation, of increased action.
Doubtless, in relation to the productive part of the inflammatory pro-
eesB^the expression '^ increased action** may be in some sense justly
wed; for the weight of an inflamed part, or of the material separated
bom it, may be much increased by the formation of organized matter.
But the quantity of organized matter formed in an inflammation must
not be unconditionally taken as a measure of increase in the exercise of
the vital forces : for it is to be observed, that the material formed pre-
lentB only the lowest grades of organization, and that it is not capable
of development, but rather tends to degeneration, so long as the inflam-
nation lasts.
It may be but a vague estimate that we can make of the amount of
force exercised in any act of formation ; yet we may be sure that a
comparatively small amount is sufficient for the production of low organ-
inaS) such as are the fibrinous and corpuscular lymphs of inflammation.
The abundant production of lowly organized structures is one of the
278 NATURl AKD CAUSBS OF IKFLAKMATION.
features of the life of the lowest creatures, in both the vegetable and
animal kingdoms. And, in our own cases, a corresponding abundint
production is often noticed in the lowest states of vital force ; witness the
final inflammations, so frequent in the last stages of granular degenen^
tion of the kidneys, of phthisis, of cancer, and other exhausting diseases.
In all these, even large quantities of the lowly organized cells of inflaa-
matory lymph may be formed, when life is at its last ebb. And irith
these cases those correspond which show the most rapid increase of
tubercle and cancer, and of lowly organized tumors, when the health is
most enfeebled, and when the blood and all the natural structures an
wasting.
From these considerations we may conclude that the productive pari
of the inflammatory process is not declaratory of the exercise of a large
amount of formative or organizing force ; and this conclusion is confirmed
by observing that development, which always requires the highest and
most favored exercise of the powers of organic life, does not occur while
inflammation lasts. The general conclusions, therefore, tnay be, as wd
from the productive as from the destructive effects of the inflammatory
process, that it is accomplished with small expenditure of vital force;
and that even when large quantities of lymph are lowly organized, sooh
an expression as '' increased action*' cannot be rightly used, unless we
can be sure that the defect of the formative power, exercised in the
proper tissue of the inflamed part, is more than counterbalanced by the
excess employed in the production and low organization of lymph.
It may be said that the signs of inflammation are signs of increased
action. But these are fallacious, if, again, by increased action be meant
any increased exercise of vital force. The redness and the swelling of
the inflamed part declare the presence of more blood ; but this blood
moves slowly ; and it is a quick renewal of blood, rather than a large
quantity at any time in a part, that is significant of active life. An
abundance of blood, with slow movement of it, is not characteristic of
activity in a part ; it often implies the contrary, as in the erectile tissues,
and the cancellous tissue of bones.
The local increase of heat is too inconstant to afford ground for judging
of the nature of inflammation.* When manifest, it is not, I think, to be
exactly compared with that of an actively growing part, or of one which
is the seat of " determination ** of blood, or of " active congestion.** In these
cases, the heat is high chiefly because the blood, brought quickly from the
heart, is quickly renewed ; but, in an inflamed part, the blood is not so
renewed ; it moves more slowly. The heat may, indeed, be in some
measure ascribed to this condition ; for the quickly moving blood around
the inflamed part may communicate its heat to that which is moving
more slowly. But the proper heat of inflammation (I mean that which is
measurable by the thermometer) cannot, I think, be wholly thus explained.
* See, especially, v. BarensprQng, in MuUer*8 Archiv, 1852, p. 208.
»A piiTii y anu IT, may ue ai uuce oujeuieu iiiai. we uave iiu evmence
le hottest inflamed parts are those in which the most destructive
108 are going on. Still, in relation to the question, how far the
led heat is a sign of the quantity of formative force that is being
ed, we may argue that, as the general supply of heat in our bodies
red from oxidation or combustion of wasted tissues or of surplus
i>i in these local augmentations of heat, the source is rather from
imilar destruction of organized substances, than from increased
ion of them. If it be so, the increased heat will give no ground
;arding the inflammatory process as the result of a greater exer-
formative force than is employed in ordinary nutrition ; none for
ig of it as increased nutrition, or increased action. Rather, this
%y be added to the endences, that the inflammatory process pro-
of diminished formative force, and of a premature and rapid
ration, in the affected part.
ins endeavoring to estimate the difference between the normal and
ammatory modes of nutrition, in regard to the quantity of forma-
other vital force exercised in them respectively, I have also stated
ef differences in relation to the quality or method of nutrition.
most general peculiarity of the inflammatory method is the con-
» of the two distinct, though usually coincident, events of which
spoken at such length ; namely, 1st, the impairment or suspension
nutrition of the proper substance of the inflamed part ; and, 2d,
ndation, from the blood, of a material more than sufficient in
J for the nutrition of the part, but less than sufficient in its
y of development.
280 NATURE AND CAUSES OF INFLAMUATION.
cerned, some inflammations might be classed with atrophies or degenen-
tions ; but the concurrent production of lymph is distinctive of them.
On the other side, the inflammatory mode of nutrition is distingouhed
from hypertrophy by the failure of the nutrition of the inflamed pirt
itself. So far as mere production and formation of organisms are oon-
cerncd, some inflammations might be paralleled with hypertrophies; but
the organization of the lymph commonly falls short of that proper to tlie
part in which it is exuded ; and the substance of the part, instead of
being augmented, is only replaced by one of lower organization.
And, lastly, from the production of new growths, such as tumors, the
inflammatory process is distinguished by this, — ^that its organized pro-
ducts, though like natural tissues of the body, are usually infiltrated,
fused, and interwoven into the textures of the inflamed parts ; and thtt,
when once their development is achieved, they have no tendency to
increase in a greater ratio than the rest of the body.
I am well aware that these can be accepted as only the generally dis-
tinguishing characters of the complete inflanmiatory process. Cases
might be easily adduced in which the border-lines are obscured ; inflam-
mations confounded on one side with atrophies, on another with hype^
trophies, on a third with tumors, and, on others, with yet other local
phenomena of disease. But the same difficulties are in every department
of our science ; yet we must acknowledge the value of general distinc-
tions among diseases even more alike than these are.
The case that I have chosen for illustrating the general nature of the
inflammatory process is one representing the disease in its simplest form
and earliest stage, manifesting only the formation of lymph, and such a
change as the softening or absorption of the inflamed part. This is but
the beginning of the history: but, if the inflammation continues, or
increases in severity, all that follows is consistent with this beginning;
all displays the same double series of events, the same defective nutrition
of the part, and the same production of low organisms. But these addi-
tions are observed : the part is more and more deteriorated, and perishes
in the mass, or in minute fragments ; the newly-organized products, not
finding the necessary conditions of nutrition, partake in the degenerative
process, and, instead of being developed, are degenerated into pus, or
some yet lower forms, or perish with the tissues in which they are im-
bedded.
Respecting, now, the cause of inflammation, I shall not say more of
its exciting causes than that, from the external ones, which alone we can
at all appreciate, wc may derive a confirmation of the opinion I have ex-
pressed concerning the nature of the process. They are such as would
be apt to produce depression of the vital forces in a part ; all being, I
think, such as, when applied with more severity, or for a longer time,
lead, not to inflammation, but to the death of the part. If a certain
HATUKB AND CAUSES OF INFLAMMATION. 281
excess of heat will inflame, a certain yet greater heat will kill : if some
nolence will inflame, a greater violence will kill ; if a diluted chemical
agent will only irritate, the same concentrated will destroy the part.
IDie same may be said, I think, of cold, and all the other external excit-
ing causes of inflammation. I am aware that other explanations of their
action are given ; but none seem to me so simple or so consistent with
ibe nature of the process that follows them, as this, which assumes that
ihey all tend (as it may be said) to depress the vital forces exercised
in the affected part. They may be stimulants or excitants of the sensi-
tive nerves of the part, but they lead to the opposite of activity in its
nutritive processes. In the reaction which follows the application of
Mwieof them, they may seem to have been the excitants of nutritive action ;
bot if the inflammatory state ensues, the formative process, we have seen,
ii really diminished.
The proximate causes, or immediately preceding conditions, of inflam-
mstion appear to be various perversions of the necessary conditions of
lealthy nutrition in a part ; that is, morbid changes in either the sup-
ply of blood, the composition of the blood, the influence of the nervous
force, or the condition of the proper substance of the inflamed part.
Any one or more of these four conditions of nutrition being changed in
qnidity may initiate an inflammation. A change of quantity more usually
produces either an excess or deficiency of nutrition in the part, or some
process different from inflammation. Thus, a diminution or withdrawal
of the blood without alteration of its quality is usually followed by atrophy,
d^neration, or death : a mere increase of blood in a part may produce
hypertrophy, or something more nearly resembling inflammation, yet
&lling short of it. Similar effects may ensue from a mere increase
or decrease, or abstraction, of nervous force. Change in the quality,
whether with or without one in the quantity, of the conditions of nu-
trition, appears essential to the production of the phenomena of inflam-
mation.
I will endeavor now to show that inflammation may follow such per-
version or qualitative change in each of the conditions of nutrition, even
though all the rest of them remain for a time in their normal state:
selecting, for this purpose, such cases of inflammation as we may trace,
proceeding, in the first instance, from the uncomplicated error of a single
condition of nutrition.
I. Inflammation may perhaps be produced — it certainly may be com-
menced, and in some measure imitated — ^by changes in the bloodvessels ;
changes attended with alteration of their size, or their permeability, or
the other qualities by which they affect the supply of blood to a part.
This may be concluded from the similarity to some of the phenomena of
inflammation which may be observed in certain cases of mechanical ob-
struction to the venous circulation. In a case of ascites from diseased
282 NATURE AND CAUSES OF INFLAMMATIOIT.
heart or liver, the peritoneum often contains coagula of fibrine floating
free in the serum, though no organ may present appearances of having
been inflamed. In such a case, moreover, I have found the fibrine de-
veloping itself in the form of nucleated blastema, even while floating
free. In another case of mechanical dropsy, I have found the fluid of
anasarca in the scrotum containing both fibrine and abundant Ijrn^
corpuscles, like those in the fluid of an inflammatory exudation. In like
manner, an apparently uncomplicated obstruction at the left side of the
heart may produce many of the phenomena of bronchitis. Such as tbese
are the cases through which mechanical congestions of blood connect
themselves with inflammation. And if to these we add the constancy of
increased vascularity among the phenomena of inflammation, they may
be sufficient to make us believe, that disturbances in the circulation of •
part may produce some of the principal phenomena of inflammation, even
though all the other conditions of nutrition are, in the first instance,
unchanged. But I know no other good evidence for the belief; and I
think we should not lay much stress on these cases, since they display
an imitation of only some parts of the process of inflammation ; namely,
the fulness of the vessels, the retarded blood, and the exudation of orgih
nizable matter. The nutrition of the proper tissues of a part with merely
obstructed circulation suffers but a trivial loss or disturbance, in compari-
son with that which would . accompany an inflammation with an equal
amount of retardation in the movement of the blood. So far as the exu-
dation in an inflamed part depends on the altered mechanical rehitions of
the blood and vessels, so far may similar alterations alone produce eflfecte
imitating those of inflammation ; they may also be the beginning of the
more complete process ; but I believe that the merely mechanical distur-
bances of the circulation are no more adequate alone to the explanation
of the whole process of inflammation, than the normal movements of the
blood are adequate to the explanation of the ordinary process of nu-
trition.
II. We may speak much less equivocally of the influence of the state
of the blood itself in causing inflammations; for there can be little
doubt that a very great majority of the so-called spontaneous or consti-
tutional as distinguished from traumatic, inflammations, have herein their
origin. We might anticipate this from the consideration that, in normal
nutrition, the principal factors are the tissues and the blood in their
mutual relations : but we have better evidence than this, in cases of local
inflammations occurring in consequence of general diseases of the blood.
Some instances of this are clearly proved, as, e. g. in the cases of erup-
tive fevers, when the presence of morbid materials in the blood is proved
by the effects of their transference in inoculation. Scarcely less tho-
roughly demonstrated are the cases of rheumatism and gout, of lepra,
psoriasis, herpes, eczema, erysipelas, and other such affections, whose
NATUBI AND CAUSBS OF INFLAMMATION. 288
itumal natnre-T-in other words, whose primary seat in the blood —
lily acknowledge in practice, if not in theory,
p in all these cases, local inflammations are the external signs of
leral affection of the blood : and I apprehend, that if any difficulty
in receiYing these as evidences, that the morbid condition of the
I the cause of the local inflammation, it will be through doubt whether
rrnl disease of the blood — a disease affecting the blood sent to
Mut— can produce peculiar phenomena of disease in only certain
larts of organs. But this local effect of a general disease of blood,
llustration in some of the sure principles of physiology ; especially
which I have fully illustrated in a former lecture (p. 33 et seq. and
namely, that the presence of certain materials in the blood may
ine the formation of appropriate organisms, in which they may be
irated.
in exact parallel with the facts in physiology which I then
1, that in certain general diseases of the blood, organs are formed,
products of inflammation, within which the specific morbid mate-
noorporated. Thus, in small-pox, cow-pox, primary syphilis, and
er other diseases may be transferred by inoculation, the morbid .
d from the blood is incorporated in the products of inflammation,
are enclosed within the characteristic yesicle or pustule, or infil-
lymph, just as, in the cases already cited, the constituents of urine
ledicines are incorporated in the renal cells, which are formed
the substance of the kidney ; or just as the constituents of sap
orporated in fruit.
le cases of disease produced by a demonstrable virus, we have all
dence that can be necessary to prove the principle, that a general
of the blood may be the cause of a local inflammation in one or
ircumscribed portions of a tissue. And the analogy is so close,
think we need not hesitate to receive the same explanation of
aflammations, which I have cited as occurring during morbid con-
of the blood. For although we cannot, by inoculation, prove
specific morbid material of such a disease as herpes or eczema,
: rheumatism, has been incorporated in the inflammatory products,
find great probability hereof in the many analogies which those
n present to the inoculable diseases, in their whole history, and,
Jly, in the decrease or modification of general illness which ensues
full manifestation of the local inflammation.
; be asked why a morbid material is determined to one part or
rather than another, or why, for example, the skin is the normal
' inflammation in small-pox, the joints in rheumatism, and so on, I
I we must say that we are, on this point, in the same ignorance as
concerning the reason why the materials of sweat are discharged
skin, those of urine at the kidneys, of bile at the liver, or why
eater part of the albuminous principles are incorporated in the
B, and of the gelatinous in the bones. We cannot tell ^h.^ tt\fi«A
284 NATURE AND CAUSES OF IXFLAHM ATION.
things are so, but they are familiar facts, and parallel with what I hen
assume of the incorporation of morbid materials derived from the blood.
Again, it may be said that we need some explanation of the fact tbat
the morbid condition of the blood does not influence the whole extent of
any given tissue, but only portions of it. In the secretion of urine, it
may be believed that the whole kidney is affected and works alike; bat
in the assumed separation of the virus of small-pox, only patches of the
skin are the seats of pustules ; in vaccinia and primary syphilis, onlj a
single point ; in secondary and tertiary syphilis, a certain, but sometimes
disorderly, succession of various parts ; and so on.
It must be admitted that many of the facts here referred to cannot
yet be explained. In some cases, however, we can assign, with mncli
probability, the conditions that determine the locality in which a genenl
disease of the blood will manifest itself by inflammation. In some in-
stances, it is evident that the localization is determined by such as we
may call a weakened or depressed condition, a state of already impaired
nutrition, in some one part. For instance, when a stream of cold air is
impelled on some part, say the shoulder, of a person disposed to rheor
• matism, it determines, as a more general exposure to cold might do in
the same person, the rheumatic state of the blood, with all its general
symptoms ; but it determines, besides, the part in which that rheumatic
state shall manifest itself first or alone. The depressed nutrition of the
chilled shoulder makes it more liable than any other part to be the Best
of inflammation excited by the diseased blood.
Or, again, when a virus is inserted, as in all cases of poisoned wounds,
the local inflammation produced by the disease with which the whole
blood is infected will commonly have its seat in the wounded part. The
virus must have produced some change in the place in which it was in-
serted, as well as in the whole mass of the blood. The change is not
merely that of a wound ; for a simple wound made in the same person,
at the same time, will not similarly inflame ; it is a change due to the
direct influence of the virus. And the part thus changed may long
remain in a peculiar morbid state, and peculiarly prone to inflammation
from diseased blood. Thus, an infant was vaccinated in the middle of
June, and the disease had its usual course ; six ordinary vesicles formed
in the punctures in the left arm, and common cicatrices remained, and
all appeared well. In the middle of July, inflammation of the left axil-
lary glands ensued. When I saw the child on August 21st, the glands
were very large, and partially suppurated, and there was extensive in-
flammation of the skin of the upper arm. On August 30th, the pus
having been partially discharged by incision, the glands had subsided,
but superficial inflammation of the integuments existed still, and now
there was, on the middle of each vaccine cicatrix, a distinct circular low
vesicle, not unlike that of the true vaccine eruption, except that it was
not umbilicated, and appeared to have an undivided cavity.
HATUBB AKD CAUSES OF IKFLAMMATION. 285
Such cases are, probably, only examples of a general rule, that a part
iriuMe natural force of nutrition is in any way depressed, is, more than
t healthy part, liable to become the seat of chief manifestation of a
general blood-disease. A part that has been the seat of former ^disease
'' or iigory, and that has never recovered its vigor of nutrition, is always
t 80 liable ; it is a weak part. Thus, the old gouty or rheumatic joint is
apt to receive the brunt of the new attack. And the same may happen
in • more general way. A man was under my care with chronic inflam-
mation of the synovial membrane of his knee, and general swelling about
it: he was attacked with measles, and the eruption over the diseased
bee was a difiused bright scarlet rash. A patient under Dr. Budd's
nre had small-pox soon after a fall on the nates : the pustules were
tUnly scattered everywhere, except in the seat of former injury, and on
tikis they were crowded as thickly as possible. Thus, too, when a part
lias been injured, and, it may be, is healing, a disease having begun in
the blood will manifest itself in this part. Impetigo appears about
blows and scratches in unhealthy children ; erysipelas about the same in
men with unhealthy blood.
Such are some of the cases in which we seem able to explain the ap-
parent choice of locality for inflammation, made by a morbid material
which is diffused through all the blood. Many remain unexplained ; if
it were not so, this portion of pathology would be a singular exception
to the general condition of the science. But these difiBculties afford no
warrant for the rejection of a theory, of which the general probability
18 affirmed by so many analogies, by the sufficiency of its terms for the
expression of the facts, and, it may be added, by nearly every particular
in the constitutional treatment of local inflammation. For, I suppose
there are few parts of the medicinal treatment of local inflammation, for
which any reason can be shown, unless it be assumed that the medicine
corrects some morbid condition of the blood.
Let it be added that the state of the blood may, in part, or chiefly,
determine, not only the locality, but also the degree and form of the
inflammation. It may, as Dr. Ormerod has well expressed it, ^^ imprint
on the morbid product (of inflammation) certain tendencies which take
effect after the morbid products have entered upon a condition of com-
paratively independent existence."^ But on this point I need not dwell;
for a large portion of Lecture XIY. is devoted to it, and it will be again
considered in the Lecture on Specific Diseases.
To test the influence of a disturbance of the nervous force in engender-
ing the inflammatory process, we must not, as is commonly done, take
of the effects of external injiury. Such an injury, or the presence
* In his Lectures on the Pathology and Treatment of Valvular Disease of the Heart, in
the Medieal Gazette, 1851. These should have been cited before, as containing the fullest
demonstration of the principle referred to here, and at p. 219.
286 NATURE AND CAUSES OF INFLAMKATION.
of a foreign body, is supposed to excite inflammation by stimulating the
nerves of the part, and by changing, through their influence, the state or
action of the bloodvessels. This may be true ; but we should remember
that iw4ien a common injury is inflicted, it acts not only on the nerves of
the part, but also on its proper tissues ; and it may so affect the state of
these tissues, that the changes produced in them may be the excitant of
inflammation, independent of the affection of the nerves. All such cases
as these are, thus, ambiguous.
For a better test, we must select cases in which the excitant of inflam-
mation acts (at least in the first instance) on the nervous system alone.
Such cases are those already referred to (p. 208). When the conjnnctifft
is inflamed after over-working of the eye, we cannot suppose that tin
light, by its direct contact, has affected the vessels, or the nutritive aet,
in the conjunctiva : it can, probably, affect either of these only throng
an influence reflected from the retina. So, when irritation of the uretbi
excites inflammation in the testicle ; when the irritation of teething ex-
cites it in any distant part ; when, as in a case quoted from Lallemand,
by Dr. Williams, inflammation of the brain followed the application of a
ligature to part of the brachial plexus ; in these and the like cases we
cannot but refer to the disturbance of the nervous force as the initiator
of the phenomena of inflammation.
Now, for the explanation of such cases as these, there appear to be
two chief theories : 1. It may be that the nerves distributed to the minute
bloodvessels of a part may be so affected that these vessels may dilate,
and their dilatation may produce the other phenomena of inflammation ;
or, 2. The disturbance of the nervous force may more directly interfat)
with the process of nutrition, inasmuch as this force exercises always some
influence in the nutrition of each part, and is (as one may say) one among
the plastiu-gic forces (p. 40.)
The first of these theories has lately acquired a dominant place in sys-
tems of pathology, especially in those of Germany. The principal form
of it, which has been maintained most prominently by Ilenle, has enlisted
the approval of even Rokitansky, and is largely received, professing to
explain all inflammations, and passing by the name of '^ neuro-pathologi-
cal," to distinguish it from the " humoral,'' and all other theories of in-
flammation. This theory may be thus briefly stated. The exciting cause
of inflammation, whether an external cause, such as an injury of a part,
or an internal one, such as diseased blood, acts, in the first instance, on
the sensitive, centripetal, or afferent nerves of the part. These it affects
as a stimulant, producing in them an excited state, which state, being
conveyed to some nervous centre, is thence reflected on the centrifugal
or motor nerves of the bloodvessels of the same, or some other related,
part. This reflection, however, is supposed to bring about a kind of an-
tagonistic sympathy, such that, instead of exciting the motor forces of
the bloodvessels to make them contract, it paralyses them, and is followed
NATURE AND CAUSES OF INFLAMMATION. 287
Ij their dilatation or relaxation. This dilatation being established,
tke exudation and other phenomena of inflammation are assumed to fol-
low as natural, and most of them as mechanical, consequences.
The eminence of those who have supported this hypothesis makes one
Mtate in rejecting it ; and yet I cannot help beliodng it to be ground-
kflB. If we remember that parts may present some of the chief pheno-
mena of inflammation, though they have no nerves, as the firmest tendons
and articular cartilages ; that the degrees of inflammation in parts bear
no proportion to the amounts of pain in them when inflamed ; that the
aererest pains may endure for very long periods with only trivial, if any,
phenomena of inflammation ; that the phenomena of the so-called reflex
paralysis are rare, equivocal, and altogether insufficient for the founda-
tion of a law or general principle ; we may well think that there can be
nosnfficient ground for the invention of such an hypothesis as this. And,
if we add that, even admitting the dilatation of bloodvessels as a possible
OHisequence of the stimulus of sensitive nerves, yet the phenomena of
emi simple inflammation would be no necessary consequences thereof ;
that the varieties of inflammations would be quite unintelligible as results
of similar mechanical disturbances of the circulation ; and that the dila-
tation of bloodvessels, in any mechanical way produced, is followed by
only feeble imitations of a part of the inflammatory process ; then we
may think that the hypothesis, if all its postulates be granted, will yet
be insufficient for the explanation of the facts.
I believe that, if we would have any clear thoughts respecting the in-
fluence of the nerves in initiating inflammations, wo must first receive the
theory already referred to (p. 40 and 208), that a certain exercise of the
nervous force is habitually and directly engaged in the act of normal nutri-
tion. If we admit this, there can bo no difficulty in believing, whatever
there may be in explaining, that the perturbations of the nervous force
may engender the inflammatory mode of nutrition more directly, than by
first paralysing the bloodvessels of a part. We attain nearly to a proof
of this in the instances of altered nutrition adduced in a former lecture
(p. 41), and in those of secretions altered, not in quantity alone, but in
quality, by affections of the nervous system. It is almost inconceivable
that any of the essential properties of a secretion should be changed by
an alteration in the quantity or movement of the blood in a gland : yet
such changes are frequently manifest in the milk, tears, urine, and sweat,
under the influence of mental affections of the nervous force ; and the
analogies of secretion and nutrition give these cases nearly the weight of
proof, in the question of the influence of the disturbed nervous force in
causing inflammations.
lY. The last of the necessary conditions of normal nutrition in a part
is the healthy state of the part itself; and it appears highly probable
that a disturbance of this may initiate, and, in this sense be the cause of.
288 NATURB AND CAUSES OF IHFLAXXATIOV.
inflammation. This is probable for many reasons ; and, first, frm
analogy witb normal nutrition. Generally, tlie principal conditions of wa^
trition are in the relative and mutual influences of the elements of At
tissues and the blood. More particularly, the state of the tissues del»
mines, at least in great measure, both the quantity and the rate of noiii
ment of the blood supplied to them ; the changes of the tissues, wbethi
in growth or decrease, usually just preceding the adapted changes in tli
supply of blood (p. 58). So, we may believe, a change in a part anyhn
engendered may, by altering its relation to the blood, alter its moded
nutrition ; and some of the changes may produce the inflammatory noil
of nutrition, together with the altered supply of bloo<l, and other chsnt
teristic signs. I am dis{)08cd to think such changes would be espeds%
effective, as causes of inflammation, when they ensue in the nidimeilri
and still developing elements of the tissue ; for, as it seems to be duc^
these which determine the normal supply of blood in a part, so, probsUj^
the abnormal state of them would most affect that supply.
Secondly, we may judge the same from the analogy between infli»
mation and the process of repair. Certainly it is the state of Al
injured part, t. e, of its proper tissues, not of its ner\'es and bloodveaidlh
which initiates the processes of repair. Now some of these are m Mb
those of inflammation, that they are commonly identified, and are Ml
capable of even a refined distinction. This is, especially, the case itt
the articular cartilages, and the cornea.*
And thirdly, the influence of the condition of the proper tissues of i
part in initiating inflammation in it, is illustrated by more direct fadi;
such ns, that injuries of parts that have no vessels or nerves are follovil
by altered modes of nutrition, which are more or less exact resemblanett
of inflammation. Thus e. g. it is in the cornea, lens, vitreous huam^
and the like, after injury. In all of these, it is diflScult to imagine aay
other cause of inflammation than the altered relations between tk
tissue and the blood or the materials derived from it.
On the whole, therefore, I think wo may conclude that inflammatioi
may have its origin in disturbance of the normal condition of the proper
tissues of a part ; in such a disturbance as may be produced by injuij,
or by the proximity of disease. To this source, indeed, I should be dii*
posed to refer nearly all inflammations that originate in the direct appt
cation of local stimuli, whether mechanical or chemical. It is true, thit,
in most cases, the stimulus affects at once the proper elements of the
part, its nerves, and its bloodvessels, so that we cannot say how much d
the disease is to be ascribed to the affection of each ; but the fact that i
process, resembling, so far as it goes, that of inflammation, may euai
after injury in parts that have neither vessels nor nerves, may maki
* See Dr. Retlfern's rcsearclic9, i. c, nml compare Mr. Bowman's account of the hemlia
of wound! in the cornea, in his Lectures on the Piuts conceme<l in Operations oo the Efi
p. 20, with the obeervations already quoted from Viichow.
NATURB AND OAUSBS OF INFLAMMATION. 289
•
m beliere that, in parts that have both, the inflammation depends
on injury, or other affection, of the proper tissue.
I have thus endeavored to show that inflammation may take its rise,
may have its proximate cause, in a disturbance of any one of the con-
ditions of nutrition. In the examination of difierent cases, we find that,
eren while any three of the four chief conditions may be normal, yet a
qualitative error of the fourth may bring in the phenomena of the in-
flammatory process. In the necessity of choosing pointed cases, I may
Mem to have implied that it is usual for inflammation not only to begin,
but to be maintained, by an error in one of the conditions of nutrition :
bat this is improbable. Rather we may believe, that many of the
excitants of inflammation may affect at once more than one of these con-
ditions; and, as I stated in the first lecture on the subject, it is nearly
certain that in every inflammation, after a short continuance, all the
conditions of the nutritive process are alike involved in error.
the fbUowing are references to some of the recent essays on inilamniationi from which
tbejetder, if he have learned the main principles concerning the disease from some of the
chsacal works upon it, — such as those of Hunter, Thomson, Alison, or Gendrin, — may
gitlier the best facts and guidance for future inquiry.
J. Hughes Bennett : On Inflammation as an Anormal Process of Nutrition. Edinburgh,
1844. — And in the first of a Series of Clinical Lectures published in the Monthly
Journal of Medical Sciences, from 1850, onwards.
Braecke (as quoted by Leber^) : Bemerkungen Uber Entzundnng ; in the Sitzungsborichte
der Weiner Akademie. June and July, 1849.
Ckupenter: In an article in the British and Foreign Medical Review, vol. xviii. p. 91.
July, 1844.
Andrew Clark : In the Medical Gazette, vol. xlii. p. 286 ; and in subsequent numbers.
Gloge: Patbologische Histologic, 4to. Jena, 1850.
Henle : Rationelle Pathologic, B. L And in his ZeitschriA, especially the 2d volume.
G. M. Humphrey: Lectures on Surgery; in the Provincial Medical and Surgical Journal
1849, and following years.
Wharton Jones ; On the State of the Blood and the Bloodvessels in Inflanmiation ; in
Guy's Hospital Reports, vol. vii. 1851.
KOss (as oAen quoted by Lebert and Virchow) : De la Vascularity et de I'lnflammation.
1846.
Lebert: Physiologic Pathologique,t i. 8vo. 1845. — And in later works; especially in
papers communicated to the Gazette Medicale ; Juillet 15 et 22, 1852. In these ho
speaks of a large work on Inflammation which he is preparing for the press.
Bedfem: Anormal Nutritiorv in Articular Cartilages. Edinburgh, 1850. And, especially
in an Appendix to a Paper in the Monthly Journal of Medical Science, Sept. 1851.
Reinbardt : Ueber die Genesis der mikrosk, Elemente in den EntzOndungsproducten ; in
Tranbe*s Beitr&ge, H. IL 1846.
Rokitansky : Patbologische Anatomie, B. i.
Simon: Lectures on General Pathology. In the Lancet, 1850; and, collected, 8vo.
London, 1850.
Travers: Physiology of Inflammation and the Healing Process, 8vo. 1844.
Virchow: Essays in the 1st and 3d, and especially in the 5th volumes of his Archir
ftkr Patbologische Anatomie. And in the Ist volume of the Verhandlungen der phys.-
' mM, GesellschaA in Wflrzburg.
H. Weber : Experimente Qber die Stase in der Froschschwimmhaut, in Muller's Archir,
H. iv. 1852. In this essay, which I did not receive till this sheet was in the press, the
19
290 MORTIFICATION.
author relates experiments showing that all the essential phenomeiui of the stagnaiioB
of blood in the capillaries and small vessels of the frogV web, after the applicatioo of
stimuli, may be produced as well when the circulation has been stopped by ligatnn
round the limb, as when the circulation is fVee. His obsenratioos, with others tfattke
promises, appear likely to elucidate that phenomena of the moYament of blood in
inflamed parts for which, as I have said (p. 204), the usual, mechanical exphuntiaM
seem insufBcient.
C. J. B. Williams : Principles of Medicine, 8yo. 1843 and 1848.
The process of inflammation, so far as it can be illustrated by specimens, may be follf
studied in the Museum of the College, in the preparations Nos. 71 to 120, and in those whiek
are referred to afler the descriptions of those in the 1st volume of the Pathological Gidi'
logue. Many of the facts relating to the state of the bloodvessels, also, are illustrated bgr
the microscopic specimens in the same Museum. All the best illustrations of the proceii,
in the Museum of St Bartholomew's, may be studied by the references in the GatalofBe,
vol. i. p. xiL
LECTURE XIX.
MORTIFICATION.
Bt Mortification, or Sphacelus, is meant the death of any portion oC
the body, while the rest remains living. The term ^^ gangrene" is
commonly used in the same sense; ^'necrosis" for similar death cl
portions of bone or cartilage, or, in some recent writers, of any other
tissue; "necraemia" for a corresponding death of the blood. The
dead piece of tissue is called a ^' slough,'' or, if it be bone, a '^ seques-
trum." The process of progressive dying is commonly called " sloughing,"
a term which is, however, also applied to the process by which a slough
is separated, with the same meaning as ^' exfoliation" is used for the
process of separating a '^sequestrum" or dead piece of bone. None of
these terms, however, are used unless the portions of dead tissue be
visible to the naked eye. It is probable that what is ejected from the
tissues in the ulcerative process is quite dead ; but, so long as it is
in the form of minute particles, visible only with the microscope, we
speak of the disease as ulceration, not sloughing or mortification. The
two processes are, however, often mingled, and can be only in general
terms, and in well-marked examples, distinguished (p. 272).
It might, also, be difficult to define, in precise terms, this death of
parts from some examples of their degeneration. We may doubt, some-
times, whether the degenerative changes, imitated, as certain of them are,
by chemical changes in the tissues after death, are not consequences of
the total cessation of the influence of vital forces ; and it seems nearly
certain that degeneration of a part may proceed to its death, and is very
apt to do so when, during progress, many of the conditions of nutrition
are at once interfered with. In a general view we may distinguish the
CAU8B8 OF MORTIFICATION. 291
^
dflgeneration of a part from its death by this — ^that the degenerate part
I wfor becomes putrid, and that no process ensues for its separation or
iaolition, sach as we can see in the case of a dead part. However de-
generate a tissue may be, it either remains in continuity with those
tfoond it, or is absorbed. If the same tissue were dead, those around it
would separate from it, and it would be ejected from them.
Still, it may not be pretended that degeneration and death are sepa-
nted by a strong border-line. Rather, many of the instances of morti-
teation to which I am about to refer may be read as histories of the
tmiffltion from one of these conditions to the other. It will appear that
apart may degenerate even to death while the rest of the body remains
aEre ; that, as a certain diminution of the supply of arterial blood may
lead to degeneration, so a greater diminution may lead to death ; that,
as a certain amount of inflammation has always in it a defective nutrition
of the inflamed part, so, in a greater amount, the death of the same part
ensues ; and that the same agent may kill one portion of a tissue and
inflame the portions around it. Of all such cases we might say that the
local death is the extreme of degeneration.
A convenient method of studying the causes of mortification may be
to divide those among them that are explicable into the direct and the
indirect ; a. e. into such as disorganize and kill the tissues at once, and
directly, though sometimes slowly, and such as do so indirectly, by
depriving them of some or all of the conditions of their nutrition. Such a
division, however, must not lead us to forget that, in many cases, mor-
tification is the result of many concurring causes of both kinds.
I. In the first class we may reckon the mortifications that are the
extremes of degeneration. But these can rarely be observed in unmixed
examples. The more evident instances are those which result from great
heat, rapidly decomposing chemical agents, and severe mechanical injury.
The appearances of the dead tissues are, in these cases, modified by the
presence of blood in those that are vascular, and by the blood being
killed in and with them : but the state of the blood is no cause of their
death; the tissues and the contained blood are killed together; and
the same mode and consequences of mortification would be manifested
in the non-vascular tissues.
Now, as I just suggested, it may be observed of all these destructive
agents, that when they are applied in smaller measure, the effect of the
injury is not to kill the part at once, but to excite an inflammation in it ;
and the inflammatory degeneration, thus added to the damage the part
sustained from the direct efiect of the injury, may lead to an indirect or
secondary mortiflcation. To this mixed origin, probably, many of the
cases of traumatic gangrene may be ascribed, which are not manifest
very speedily after the injury ; in these we may say that a severe injury
292 OAUSES OF MORTIFICATION.
has so nearly disorganized a part, that the subsequent inflammation, irid
the concurrent defective nutrition, has completed its death. But,
mechanical violence, heat, or chemical action, may kill a tissue at once,
without the intervention of inflammation ; and although, in the case of
the vascular tissues, it is scarcely possible to separate the influence of the
injury on their proper elements, from that which is, at the same time,
inflicted on their blood and vessels, yet we must consider the phenomena
of mortification as having their seat, essentially, in the elements of the
tissues. Whatever we understand as the life of a part, that life may
cease ; and as the life of a part is its own property, maintained, indeed,
by the blood and other conditions of nutrition, yet not derived from
them, so may that life cease, or, as it is said, be destroyed, without
interference of the blood or any other exterior conditions of nutrition.
The immediateness of such death of a part is shown by the rapiditj
with which it is manifested. It is nearly instantaneous on the applica-
tion of extreme heat or the strongest mechanical agents ; slower after
mechanical injury : but within twelve hours of the infliction of a Wow
the struck or crushed part may be evidently dead ; there may be littk
or no ecchymosis, no sign of inflammation, no pain, except that which
directly followed the injury, and, in the case of a bone, no apparent
change of texture ; but the piece of tissue is killed in the midst of the
living parts ; its recovery, by the re-establishment of its relations with
the blood, is not possible : it cannot even be absorbed.
II. Among the instances of indirect mortification of parts, the moat
numerous are those in which nutrition is made impossible by some defect
either (1) in the quantity, or (2), in the movement of the blood.
Defects in the quantity of blood have been already noticed as leading
to death of parts (p. 37). The following are the chief general methods
of the events : —
The main artery of a part may be closed by pressure, or by some
internal obstruction. Thus, sometimes, sloughing of the foot or leg fol-
lows ligature of the femoral artery for popliteal aneurism ; or sloughing
of part of the brain may follow ligature of the common carotid artery;
and in this case, the diff'erenco. and yet the close relation, between the
death of a part and its degeneration, are well shown (compare p. 37 and
103). Thus, also, through equal internal obstruction of main arteries,
sloughing may follow blows which crack the internal and middle coats,
and let them fold inwards across the stream of blood:* or, the blocking
of masses of fibrine, washed from the left valves of the heart, and arrest-
ed in the iliac or some other artervit or the closure of inflamed arteries.
Portions of tissue may similarly perish when, by injury, or by pro-
gressive ulceration or absorption, all their minute bloodvessels are de-
stroyed, and their supply of blood cut off*. Thus necrosis may follow
• Two such specimens are in tlic Museum of St. Bartholomew's.
\ See Dr. Kirkcs's essay in Meil.-Chir Trau.-*., vol. xxxv.
vessels, the peritoneum, hitherto ted by them, perishes, and is
d fts a grayish or yellowish-white slough. In like manner, ulcera-
ita. progress, may so undermine or intrench a part, that at
; dies through defect of blood : thus, often, small fragments of
e detached in strumous disease of the tarsus and other parts.
Qilarly, through mere defect of blood, the centre of a tumor may
and here, again, is manifest the relation between the death, and
d frequent degeneration, of an imperfectly nourished part.
ffect of pressure constantly maintained on a part may be a simi-
dnced mortification ; the part may die because its blood is pressed
and not renewed ; but more commonly, as we see in bed-sores,
ition ensues, and the death of the part has a double or mixed
) gangrene, also, is without doubt, in many cases, due, in a measure,
tive quantity of blood : but it is a more complicated example of
ition than any of the foregoing, and I shall therefore again refer
a said that parts may die through defective movement of blood.
be present in sufficient or excessive quantity ; but it may be
tagnant. So far as the proper elements of the tissue are con-
there may be little difference in their modes of death, or in their
mt changes, in these two sets of cases ; but, as seen in the mass,
tf dead through defect of blood is very different from that dead
stagnation of blood. In the former, we find little more than its
nctures dried and shrunken or disorganized ; in the latter, the
B of abundant blood, and often of substances exuded from the
id Y^sels, lie mingled with the proper structures, having died
■n. Hence, mainlv« the differences between the mortifications
294 CAUSES OF MORTIFICATION.
arteries do : the vessels of the part thus become gorged with blood, ad-
mitted into them in larger quantity than it can leave them, and so morti-
fication ensues after intense congestion or inflammation of all the tissues.*
Mere passive congestion of the vessels of a part may, in enfeebled
persons, lead to mortification : but this is a rare event, for unless a put
be injured, or of itself already degenerate, it may be maintained by a
very slow movement of the blood.
The congestion which more commonly leads to mortification is that
which forms part of the inflammatory process. It is, perhaps, to be re-
gretted that the cases of this class should have been taken as if thej
were the simplest types of the process of mortification, and that tlie
process should have been studied as an appendage, a so-called termina-
tion, of inflammation : for, in truth, the death of an inflamed part is a
very complex matter ; and in certain exti^mples of it, all the more aimpie
causes of mortification may be involved. Thus (1) the inflammatory con-
gestion may end in stagnation of the blood, and this, as an indirect came
of mortification, may lead to the death of the blood, and that of the
tissues that need moving blood for their support. But (2) a degeneration
of the proper textures is a constant part of the inflammatory process;
and this degeneration may itself proceed to death, while it is concurrent
with defects in the conditions of nutrition. And (3) the exudation of
fluid in some inflamed parts may so compress, and by the swelling so
elongate, the bloodvessels, as to diminish materially the influx of fresh
blood, even when little of that already in the part is stagnant.
All these, and perhaps other, conditions may concur in the mortifica-
tion of an inflamed part ; and their united force is commonly the more
effective, by being exercised in a previously defective or degenerate con-
dition of the inflamed tissue. The second of them, I think, has been
too little considered ; for by it, more than by any other event, we maj
understand the sloughing that ensues in the inflamed parts of enfeebled
persons. The intensity of an inflammation is not, alone, a measure of
the probability of mortification ensuing in its course : neither is mere
debility; for we daily see inflammation without death of parts in the
feeblest patients with phthisis and other diseases : rather, when mortifi-
cation happens in an inflamed part, it seems to be through the occ1I^
rence of the disease in those that have degenerate tissues because of old
age or defective food or other materials for life, or through habitual in-
temperance. It is afl if the death of the part were the consequence of
the defective nutrition, which concurs with the rest of the inflammatory
process, being superadded to that previously existing in the part. To
the same occurrence we may, in some measure, ascribe the mortification
of parts after comparatively slight injuries in the aged and intemperate:
already degenerate, they perish through the addition of what, in heal-
* Thii difference in the effects of constrictions of parts is particularly described by Kr
B. C. Brodie : Lectures on Surgery and Pathology, p. 304.
may be the explanations of the local death that may occur in
ktioii; bat^ in many more cases of what appear as mortifications
ed partS| the death is the first event in the process, and the in-
on appears as its consequence ; or else the death and the in-
on are coincident in different parts of the same tissue. To these
hall again refer.
lile gangrene we commonly find a very large number of con-
oinistering to the death of the affected part. First, occurring,
me implies, in the old, and often in those that are old in struc-
ler than in years, it affects tissues already degenerate, and at
extremity and most feebly nourished part of the body. I think
some cases, its beginning may be when the progressive degene-
' the part has- arrived at death. But, if this do not happen, some
* disease, even a very trivial one, kills that which was already
Bad ; as a severe injury might kill any part, however actively
Nfow, when death has thus commenced, it may in the same
extend more widely and deeply, with little or no sign of attend-
ise ; the parts may successively die, blacken, and become dry
relied ; in this case, the senile gangrene is a dry one. But, more
ly, when a portion of a toe or of the foot has thus died, the parts
If within it become inflamed ; and in these, degenerate as they
eady, the further degeneration of the inflammatory process is
re ; and thus, or in this extent, by progressive inflammation and
le gangrene, moist, though senile, spreads. In either case, the
I of the gangrene is favored by many other things ; especially
iefective muscular and elastic power, and by the narrowing or
ion, of the degenerate arteries of the part ; by the defective
296 CAUSBS OF MORTIFIOATIOir.
III. In the foregoing cases, we seem able, in some measure, to explain
the occurrence of morti£cation. But there are yet many cases in wbidi
explanation, except in the most general and vague terms, is far moie
difficult. In some, the local death is to be ascribed to defective quifity
of the blood, or to morbid materials in it. Among these, the instances
of sloughing of the cornea observed in animals, and more rarely in men,
whose food is deficient in nitrogen ; and those of mortifications of the
extremities that have ensued after eating rye with ergot, may prove the
general principle, — that certain parts, even small and circumscribed
parts, may die through defects or errors of the blood, which yet do not
quite hinder its maintaining the rest of the body. They may, thus, be
types of a large class of cases, in all of which the death of a portion of
tissue seems to ensue through some wrong in the blood by which tbeir
mutual influence is destroyed; of which cases, therefore, we mayny
that, as there are morbid conditions of the whole blood in which local
inflammations may have their origin, so are there others in which local
deaths have theirs.
Boils and carbuncles, for example, are of this kind. The sloughs, so
often separated from them, are pale and bloodless ; they are not portions
of the tissue that have died in consequence of stagnation of blood in
them : they are white sloughs in the midst of inflamed parts. In boib,
the first event of the disease may appear in the small central slough;
in such cases, the surrounding inflammation may appear to be the conse-
quence of the slough ; but, much more probably, it is the result of a
lesser influence of the same morbid condition of the blood. In the idio-
pathic sloughing of the cellular tissue of the scrotum, the local deatfh
is evidently, in some cases, the first event df the disease. To this class,
also, of mortifications in consequence of morbid conditions of the blood,
wo must refer, I presume, the cases of hospital gangrene ; those of the
most severe and most rapidly extending traumatic kind ; those of the
sloughings of mucous membranes and other parts, that sometimes ensue
in typhus, scarlet fever, and other allied diseases, when they deviate from
their ordinary course ; the sloughing of sy|)hilitic sores, and many otherSi
Lastly we may enumerate among the causes of death of parts the
defect of nervous force : but the examples of this have been related in a
former lecture (p. 42) ;* and it only needs, perhaps, to be said here that
this defect may mingle its influence with many other more obvious causei
of mortification. When a part is severely injured, its nerves suffer pro-
portionate violence, and their defective force may add to the danger of
mortification ; in the old, not the blood, of the tissues alone, are degene-
rate, but the nervous structures also ; and defective nervous force may
be, in them, counted among the many conditions favorable to the senile .
* There are yet many cases which I can neither explain nor classify ; such as those
from the effects of animal poisons, malignant pustule, peculiar gangrenes of the skin, and
many others. On all these, and, indeed, on the whole subject of mortifications, the reader
will ^d DO work that he can study with so much profit as the lectures of Sir B. C. Brodie.
CAUSES OP MORTIFICATIOy. 297
pagrene ; and so, yet more evidently, the sloughing of compressed parts
ii peculiarly rapid and severe when those parts are deprived of nervous
Ibree by injury of the spinal cord, or otherwise.
While the causes of mortification are so manifold; while it is in fact,
the end of so many different affections, it is not strange that the appe<ar-
■ices of the dying and dead parts should be extremely various. The
dumges in them (independent of those produced by great heat, caustics,
or other such disorganizing agents) may be referred to three chief sources :
■amely, (1) those that ensue in the dying and dead tissues ; (2) those
m the blood, dying with the tissues, and often accumulated in them in
vmatural abundance; (8) those which are due to the inflammation or
flAer disease or injury, which has preceded the death of the part, and
«f which the products die with the tissue and the blood, and change
with them after death.
But though we may thus classify the morbid changes in mortified
pirts, yet we can hardly enumerate the varieties which, in each class,
ire due to the previous diseases of the part, or to external conditions;
nch as differences of temperature, of moisture, and others. All the
chemical changes which, in life, are repaired and unobserved, are here
eamulative ; all those external forces are now submitted to, which, while
4e parts were living, they seemed to disregard ; so exactly were they
idJDsted in counter-action. It is, therefore, only in typical examples
dktt mortifications can be well described. The technical terms applied
to them have been already mentioned; and "dry" and "moist" signify
tile chief differences dependent on the quantity of blood and of inflam-
nttcry products in the dead parts. "Dry gangrene" is usually pro>
ceded by diminished supply of blood to the part; "moist or humid gan-
grene" by increased supply, and often by inflammation; the former,
Bore slowly progressive is usually a "chronic," or, as some have called
it, "cold gangrene;" the latter an "acute or hot gangrene."
Among the examples of mortification due to defective supply of blood,
ud therefore classed as dry gangrenes, great differences of ap[>earancc
ire due to the degrees in which the dead parts can be tried. Ah it may
be observed in the integuments of the leg, for example, it may 1^ noticed
Alt, in the first instance, the part about to die, appears livid, or mottled
vith various dusky shades of purple, brown, or in^ligo, through which it
Nems to pass as its colors change from the dull ruddiness of stagnant or
tirdy blood towards the blackness of complete death. It becomes colder,
ttd gradually insensible ; its cuticle separates, and is raised in blisters
bj a serous or more or less blood-colored or brownish fluid. Then, as
die cuticle breaks and is removed, the subjacent integument, hitlierto
kept moist, being now exposed to the air, gradually becomes drier;
^thering, mummifying, becoming dark brown and black, having a
Mouldy rather than a putrid smell ; it is changed, as Kokitansky says,*
* PMbologische Anatomie, i. p. 237.
298 CAU8BS OF MO&TIFIOATIOH.
like organic substances decomposed with insufficient moisture and with
separation of free carbon. Such are the changes often seen in the dij
senile gangrene, and in that which may follow obstruction of the miin
arteries in young persons : but, very generally, as the interior parts of
the limb cannot be dried so quickly as the exterior, and are, perh«pB,
less completely deprived as their supply of blood, they, or portions d
them, become soft and putrid, while the integuments become dry and
musty.
In other cases of mortification similarly caused, the dead parts, thon^
deprived of blood, cannot become dry ; either they are not exposed to
air, or they are soaked with fluid exuded near them. In these instances
the sloughs may be dark ; but they are commonly nearly white ; and
hence one of the grounds for the technical distinction of white and black
gangrene. Such white sloughs are commonly seen when the peritoneum
mortifies, after being deprived of blood by ulceration gradually deepening
in the walls of the digestive canal ; and, sometimes, in the integuments
over an abscess, when the cuticle has not previously separated. If this
have happened, the dead and undermined integument may become dry
and horny ; but if the cuticle remain, it is commonly white, soft, and
putrid.
The typical examples of the moist gangrene are those which occur in
inflamed parts, and chiefly in consequence of inflammation, and to which,
therefore, the names of '' acute" and ^^ hot" gangrene have been applied.
We must not reckon among these the cases in which the death of the
part precedes, or has a common origin with, the inflammation ; for in
these, as in boils, carbuncles, and hospital gangrene, the slough is com-
monly bloodless, white or yellowish-, or grayish-white, and, if it were
not immersed in fluid, would probably be dry and shrivelled. The mor-
tification that occurs during inflammation, and as in part a consequence
of it, finds the tissues full of blood, and often of exuded lymph and
serum, which all perish with them.
If such a process be watched in an inflammation involving the integn-
ments, or in senile gangrene rapidly progressive with inflammation, or,
as in the most striking instance, in the traumatic gangrene following a
severe injury of a limb, the parts that were swollen, full red, and hot,
and perhaps very tense and painful, become mottled with overspreading
shades of dusky brown, green, blue, and black. These tints, in morti>
fication after injuries, may, sometimes, seem at first like the effects of
ecchymoses; and often, after fractures of the leg, a further likeness
between the two is produced by the rising of the cuticle in blisters filled
with serous or blood-colored fluids at the most injured parts. But the
coincident or quickly following signs of mortification leave no doubt of
what is happening. The discolored parts become cold and insensible,
and more and more dark, except at their borders, which are dusky red ;
a thin, brownish, stinking fluid issues from the exposed integuments ; gas
0AU8I8 OF MORTIFIOATION. 299
dvolred from sfanilar fluids decomposing in the deeper seated tissues,
id its babbles crepitate as we press them ; the limb retains its size or
Jarges, but its tissues are no longer tense ; they soften as in infiamma-
m, bat both more rapidly and more thoroughly, for they become utterly
itten. At the borders of the dying and dead tissues, if the mortification
» still extending, these changes are gradually lost ; the colors fade into
le dusky red of the inflamed but still living parts ; and the tint of these
irts may afford the earliest and best sign of the progress towards
Bsth, or the return to a more perfect life. Their becoming more dark
nd dull, with a browner red, is the sure precursor of their death ; their
lightening and assuming a more florid hue is as sure a sign that they
re more actively alive. Doubtless the varieties of color indicate,
vqpectively, the stagnation and the movement of the blood in the parts
lUeh, thus situated, may, according to the progress of their inflammation,
to added to the dead, or become the apparatus of repair.
The interior of a part thus mortified corresponds with the foregoing
faicription. All the softer tissues are, like the integuments, rotten,
nft, putrid, soaked with serum and decomposed exuded fluid; ash-
eokred, green, or brown ; more rarely blue or black ; crackling with
mious gases extricated in decomposition. The tendons and articular
cvtilages in a mortifled limb may seem but little changed ; at the most
they may be softened, and deprived of lustre. The bones appear dry,
Uoodless, and often like such as .have been macerated and bleached;
Aeir periosteum is usually separated from them, or may be easily and
desnly stripped off. But these harder and interior parts of a limb
cither die more slowly, or more slowly manifest the signs of death, than
io those around them ; for, not only do they appear comparatively little
dinged, but, often, when all the dead soft parts are completely sepa-
nkted from the living, the bone remains continuous, and its medullary
Tenels bleed when it is sawn off. Usually, also, after complete spon-
taneous separation of the mortified part of a limb, the stump is conical ;
tlie outer parts of it having died higher up than the parts in its axis.
Another appearance of mortified parts, characteristic of a class, is
vesented after they have been strangulated. I have mentioned the
Kfference which iii these cases depends on whether the strangulation
lave been suddenly complete, or have been gradually made perfect (p.
!98). In the former case, the slough is very quickly formed, and may
le ash-colored, gray, or whitish, and apt to shrivel and become dry
•fore its separation. In the latter case, as best exemplified in strangu-
aled hernia, the bloodvessels become gradually more and more full,
nd the blood more dark, till the walls of the intestine, passing through
he deepest tints of blood-color and of crimson, become completely
»lack. Commonly, by partial extravasation of blood, and by inflamma-
wj exudation, they become also thick, flrm, and leathery, a condition
fhich materially adds to the difficulty of reducing the hernia, but
800 CAUSBS OF MOBTIFIOATION.
which is generally an evidence that the tissues are not dead ; for wlien
they are dead, they become not only duller to the eye, but softer, more
flaccid and yielding, and easily torn, like the rotten tissue of other
mortified parts. The canal, which wais before cylindrical, may nov
collapse ; and now, commonly, the odor of the intestinal contents pene*
tratcs its walls.
I have spoken of the death of the blood as coinciding with that of the
part in whose vessel it is enclosed. Very commonly, when this happens,
coagulation of blood ensues in the vessels for some distance above, i t.
nearer to the heart than, the mortified parts. Hence, as it has been often
observed, no bleeding may appear from even large arteries divided in
amputations above the dead parts of sloughing limbs.
It remains now to speak of the phenomena which ensue when gangrene
ceases, and of which the end is, that the dead parts are separated firom
the living.
As for the dead parts, they only continue to decompose while, if ex-
posed to a dry atmosphere, they gradually shrivel, become drier and
darker. But more important changes ensue in the living parts thit
border them. The first change that occurs in this process (the whole of
which may be studied as the most remarkable instance of the adaptation
of disease for the recovery of health), the first indication of the coming
reparative process, is a more decided limitation and contrast of color tt
the border of the dying part. As we watch it in the integuments, the
dusky redness of the surrounding skin becomes more bright, and paler,
as if mingled with pink rather than with brown ; and the contrast reaches
its height when, as the redness of the living part brightens, the dead
whiteness or blackness of the slough becomes more perfect. The touch
may detect a corresponding contrast : the living part, turgid with moving
blood, feels tense and warm ; the dead part is soft, or inelastic, cold, and
often a little sunken below the level of the living. These contrasts mark
out the limits of the two parts : they constitute the *' line of demarcation"
between them.
The separation of the dead and living parts, which remain continuous
for various periods after the mortification has ceased and tho line of de-
marcation is formed, is accomplished by the ulceration of the portions of
the living tissues which are immediately contiguous to the dead. At this
border, and (in parts that are exposed) commencing at the surface, a groove
is formed by ulceration, which circumscribes and intrenches the dead part,
and then, gradually deepening and converging, imdermines it, till,
reaching its centre, the separation is completed, and the slough falls oris
dislodged by the discharge from the surface of the ulcerated living part
Commonly, before the border of the integuments ulcerates, it becomes
white and very soft ; so that, for a time, a dull white line appears to
divide the dead and living parts.
8BPABATI0K OF MORTIFIED PARTS. 801
Closely following in the wake of this process of ulceration is one more
itely directed towards repair. As the ulcerated groove deepens day
ky day around and beneath the dead part, so do granulations rise from
Hi sarface ; so that, as one might say, that which was yesterday ulcera-
ting is to^ay granulating ; and thus, very soon after the slough is sepa-
rated^ the whole surface of the living part, from which it was detached, is
oorered with granulations, and proceeds, like an ordinary ulcer, towards
kealing.
There is, I believe, nothing in the method of thus separating a dead
firt, thus *^ casting-off a slough,'' which is not in conformity with the
general procesB of ulceration. When a portion of the very interior sub-
itinoe of an organ dies, and is separated, there may be doubt, as in some
Bearly corresponding cases of ulceration (p. 270), whether the clearing
may of the living tissue adjacent to it be effected by absorption or by
Asintegration, and mingling with the fluid in which, after separation,
the dead piece lies. We may have this doubt in such cases as the slough-
bg of subcutaneous tissue in carbuncles not yet open, or in phlegmonous
erysipelas, or in the cases of internal necrosis ; in which, without any ex-
ternal discharge, pieces of dead tissue are completely detached from the
Irring tissue around them : and I do not know how such doubt can be
Mdved. But the separation of superficial or exposed dead parts might
be studied as the type of the ulcerative process, of which, indeed, it is in
disease the usual beginning (see p. 272), and with the more advantage,
because the sloughing of parts of limbs affords illustrations of the process
intiB^ues in which it very rarely happens otherwise. Especially, it shows
the times at which, in different tissues, ulceration may ensue, and hereby
tbe times during which, under similar conditions of hindered nutrition,
Ae tissues may severally maintain life.
The process which I have exemplified by the mortification of soft parts
biB an exact and instructive parallel in necrosis or mortification of bone ;
but there are in the phenomena of necrosis some things which deserve a
brief mention because of their clearly illustrating the general nature of
tbe process following the death of a part.
Thus (1) we find in bones a permanent evidence of the increase of
ntecalarity of the tissues around a dead part; for, in specimens of
Mcrosis, the bone at the border of the dead piece has always very
nmnerouB and enlarged Haversian canals. (2) We may often see that
tbe reparative process, on the borders of the living part, keeps pace with,
or rather precedes by some short interval, the process by which the living
uul the dead are separated : for new bone is always formed in and
beneath the periosteum at the border of the living bone, while the groove
around the dead piece is being deepened, or even before its formation
bi8 commenced. (3) Instances of necrosis show some of the progressive
changes that lead to the formation of the groove of separation. The
We at the very junction of the living and the dead becomes, first, soft
802 SEPARATION OF MORTIFIBD PABTS.
and ruddy, as an inflamed bone does. Its earthy matter, as Mr. Hunter
described, is first (by absorption, as we must suppose) removed in larger
proportion than its animal basis. This basis remains, for a time, con-
necting the dead and the living bone, both of which, retaining their
natural hardness, appear in strong contrast with it ; but soon this also is
removed, and the separation is completed. (4) From some cases of
necrosis, also, we obtain e\ddence on a question about the removal of
dead tissue. It is asked whether dead tissue may not be absorbed, and
so removed. Examples of necrosis show that in the large majority of
cases, the separation of dead bone is accomplished entirely by the
ulceration or absorption of the living bone around it ; but that, in certain
cases, especially in those in which pieces of bone, though dead, r^nain
continuous with the living, the dead bone may be in part absorbed, or
otherwise removed, not indeed in mass but after being disintegrated or
dissolved. "*" (5) In cases of necrosis we find the best examples in whidi,
apparently through want of vital force, the dead and living parts remain
long united and continuous. A piece of dead bone, proved to be dead
by its blackness, insensibility, and total absence of change, may renuun
even for months connected with living bone : and no process for its
separation is established till the patient's general health improves. (6)
Lastly, in the death of bone, we may see a simpler process for the
separation of the living tissues than that which is accomplished by ulcera-
tion. In superficial necrosis, the periosteum, at least in those parts in
which its own tissue does not penetrate, so as to be continuous with, that
of the bone, separates cleanly from the surface of the dead bone, retain-
ing its own integrity and smoothness, and leaving the bone equally entire
and smooth. No observations have yet been made, I believe, which show
how this retirement of one tissue from another is effected, or how the
bloodvessels that pass from one to the other are disposed of. Another
method of separation without the ulcerative process is observed when
teeth die, especially iu old persons. Their sockets enlarge, apparently
by mere atrophy or absorption of the walls and margins ; so that the
teeth-fangs are no longer tightly grasped by them, but become looee^
and project further from the jaw.
* Such cases arc recorded by Mr. Stanley, in whose Treatise on Diseases of the B(H)es I
need hardly say that all the phenomena of necrosis are much more fully described than
they are here. The possibility of the absorption of the dead bone seems amply proved bjr
cases (one of which I watched while it was under his care) in which portions of pegi of
ivory, driven like nails into bones, to excite inflammation for tlie repair of ununited fractures
have been removed. The absorption, I say, seems amply proved; but the method of it is
made, by the same observations, more difficult than ever to explain ; for only those portions
of the ivory that were imbeddecf in the bone were absorbed ; the portions that were not ia
contact with bone, tliough imbedded in granulations or pus, wer6 unchanged.
8PSCIFI0 DISEASSS. 808
LECTURE XX.
SPECIFIC DISEASES.
[r would be far beyond tbe design of these lectures, intended only
the illustration of the General Principles of Pathology, in its relations
h Surgery, if I were to enter largely on the consideration of the dis-
ci named specific. It will' be sufficient, I hope, and certainly will
re nearly correspond with the rest of my plan, if I describe the gene-
features of specific diseases, and their general import; and if I
Bt out, though only in suggestions, how we may more efiectually study
n; how many thhigs relating to them, which we are apt to dismiss
it words, may be subjects of deeper, and perhaps useful, thought.
The term ^'specific disease," as employed in common usage and in its
Mt general sense, means something distinct from common or simple
Mse. Thus, when a '^ specific inflammation" or a '^ specific ulcer" is
oken of, we understand that these present certain features in which
ej differ from what the same person would call a '^ common" or a ''sim>
> inflammation" or ^^ ulcer." The specific characters of any disease,
lelher syphilis or hydrophobia, gout or rheumatism, typhus, small-pox,
any other, are those in which it constantly deviates from the charac-
mcSm common or simple disease of the same general kind."*" Our first
|nry, therefore, must be, — what are these common diseases, which we
■I to be agreed to take as the standard by which to measure the spe-
k diaracters of others ?
I belieye that, in relation to inflammatory diseases and their conse-
loioes, our chief thoughts concerning such standards for comparison
t deriyed from the afiections which follow injuries by violence, or by
organic chemical agents, by heat, or any other commonly applied
MMs of disease. When such a blow is inflicted as kills a portion of
le body, its consequences afford a standard with which we may com-
we ill other instances of mortification and sloughing; and when,
nwng these, we find a certain number of examples which differ, in
M constant characters, from this standard, we place them, as it were,
U separate group, as examples of a specific disease. Or, again, when
pirt is submitted to such pressure as leads to its ulceration, we regard
^ disease as a common, simple, or standard ulcer ; and by their several
* It my not bo unnecessary to guard some students at once from the suspicion, which
m tenni in ootnmon use may suggest, that there is a correspondence between the spe-
^ of diseases and those of living creatures as studied in natural history. There is
'^ no likeness, correspondence, or true analogy between them ; and if nosological sys-
^ fnmed after the pattern of those of zoology, lead to the belief that they have any other
'*>^blanee than that of the modes of briefly describing, and of grouping double names
<^W better be disused.
804 DISTINCTIONS BETWBBN COMMON
constant differences from it, and from one another, we judge of the
various ulcers which wo name specific. In like manner, onr standard of
common or simple inflammation seems to be derived from the proceBses
which follow violence, the application of heat, the lodgment of foreign
bodies, or the application of certain chemical stimulants. And the stand-
ard of common or simple fever is that which ensues in a previously
healthy man, soon after he has received some such local injury as anj
of these agents might produce. Now, it is very reasonable that we should
take these as the best examples of common or simple disease; the best,
I mean, for comparison with those that may be called specific. For not
only can we produce some of these common diseases when we wiU, and
study them experimentally, but they manifestly present disease in its
least complicated fonn ; least specified by peculiarities cither in its cause
or in its subject. Only, in adjusting our standards of disease from them,
it is necessary that we should take the characters presented by all or bj
the great majority of instances ; since the consequences of even the sim-
plest mechanical injuries are apt to vary according to the peculiar consti-
tution of the person injured.
The terms simple and specific are sometimes applied, in equal contra-
distinction, to tiunors. Here we have no such standard of accidental or
experimental disease ; but that which seems to be taken as the measure
of simplicity in a tumor, is the conformity of its structure with some of
the natural parts of the body. The more a tumor is like a mere over-
growth of some natural structure, the more "simple" is it considered;
and the specific characters of a tumor are chiefly those in which, whether
in texture or in mode of life, it differs from the natural parts. When,
however, a tumor is diseased, — for instance, when a cancer ulcerates,—
the specific characters of the ulcer are estimated by comparison with the
characters of common or simple ulcers.
Such are, in the most general terms, the standards of common or sim-
ple diseases. The title "common" applied to them is, in another sense,
justified by the features which they present being, for the most part,
common to them and to the specific diseases. For, in the specific dis^ises,
we do not find morbid processes altogether different from those which
are taken as standards, but only such processes as are conformed with
them in all general and common features, but differ from them by some
modification or addition. In other words, no specific disease is entirely
peculiar or specific ; each consists of a common morbid process, whether
an inflammation, an ulceration, a gangrene, or any other, and of a spe-
cific modification or plan in some part thereof.
Let us now see what these modifications, these specific characters, are ;
and here, the history of tumors being reserved to the next volume, let
me almost limit the inquiry to a comparison of the inflammatory affections
of the two kinds, and select examples from only such as are, by the most
AVD 8PSCI7I0 DISEASES. 805
inenl consent, eaUed specific ; as syphilis, gout, rheumatism, the erup-
m fevers, and the like.
L Each specific disease constantly observes a certain plan or construc-
ioB in its morbid process ; each, as I just said, presents the phenomena
fa common or simple disease, but either there is some addition to these,
Wf else, one or more of these is so modified as to constitute a specific
jkaracter ; a peculiarity by which each is distinguished at once from all
HBmon, and from aU other specific, diseases. Thus, we see a patient
nth, say, two or three annular or crescentic ulcers on his legs ; and, if
■e can watch these, they are, perhaps, healing at their concave borders
il the same time as they are extending at their convex borders. Now,
ban are all the conditions that belong to common ulcers; and, in
Miutnt instances, we might find these ulcers liable to the variations of
aBBUDon ones, as being more or less inflamed or congested, acute or chronic,
fngressive or stationary ; but we look beyond these characters, and see,
k the shape and mode of extension of these ulcers, properties which
m not observed in common ones ; we recognise these as specific charac-
Itfs ; we may call the ulcers specific ; or, because we know how commonly
iKh ulcers occur in syphilis, and how rarely in any other disease, we call
Ikm syphilitic ulcers, and treat them with iodide of potassium, or some
ittcr specific ; that is, specially curative medicines. Another patient
In, say, numerous small, round, dusky, or light brownish-red, slightly
ibrated patches of inflammation of the surface of his skin ; on many of
Aem there are small, dry, white scales ; and some of them may be arranged
h a ring. Here, again, are the common [characters of inflammation :
hrt they are pecuUarized in plan and tint of redness, and in general as-
pect ; and because of these we regard the disease as specific, and call it
paoriasiB, and, because of the additional peculiarity of dusky or coppery
redness, and of the annular or some other figurate arrangement, we sus-
pect that it is syphilitic psoriasis. Or, we look through a series of pre-
parations of ulcerated intestines ; and we call one ulcer simple or catarrhal,
mother typhous, another dysenteric, a fourth tuberculous : all have the
eonuiion characters of ulcers ; but these are, in each, peculiarly or speci-
ieaDy modified in some respect of plan ; and the modifications are so
coMtant that, without hearing any history of the specimens, we may be
im of all the chief events of the disease by which each ulcer was pre-
ceded. Or, among a heap of diseased bones, we can select those whose
poiBessors were strumous, rheumatic, syphilitic, or cancerous ; finding in
tbem Bfeci&c modifications of the results of some common disease, such
M new bone, u e. ossified inflammatory deposits, arranged in peculiar
Mhods of construction, or at particular parts ; or ulcers of peculiar shape
ttd peculiar method of extension.
I need not cite more examples of the thousand varieties in which the com-
mon {dienomena of disease are modified in specific diseases. In some,
^ moat evident specific characteristics are peculiar affections of the
20
806 DISTIKCTIONS BETWEEN COMKOF
movement of the blood, as in the cutaneous erythemata ; in some, affe^
tions of certain parts of the nervous centres, as in tetanus, hydropliolna,
and hooping-cough ; in some, peculiar exudations from the blood, as Id
gout and the inoculable diseases ; in some, peculiar structures formed bj
the exuded materials, as in variola, vaccinia, and other cutaneous puBtnhr
eruptions ; in some, destruction of tissues, as in the ulcers of syphilis,
the sloughs of boils and carbuncles ; in some, peculiar growths, as in can-
cer ; in some, or indeed in nearly all, peculiar methods of febrile general
disturbance ; but, in each of all the number, phenomena admit of di8tin^
tion into those of common disease, and those in which such disease is
peculiarly modified, or by which, if I may so say, it is specificated.
The morbid process thus modified may be local or general. UBually,
in specific diseases, both local and general morbid processes are concm>-
rent, and both are, in a measure, specific ; but, although we can scarcely
doubt that there is in every case an exact and specific correspondence
between the two, yet, at present, the general or constitutional affections
of many different specific diseases appear so alike, that we derive our evi-
dence of specific characters almost entirely from the local part of the &-
ease. The premonitory general disturbances of the exanthemata, or the
slighter disorders preceding cutaneous eruptions, are, severally, so alike,
that, except by collateral evidence, we could seldom do more than goes
what they portend ; their specific modifications of common general dis-
turbance arc too slight for us to recognise them with our present know-
ledge and means of observation.
2. Observing the causes of specific diseases, we find that some, and
these the most striking examples of the whole class, are due to the intro-
duction of peculiar organic compounds, — morbid poisons, as they are ge-
nerally called, — into the blood. Such are all the diseases that can be
transmitted by inoculation, contagion, or infection. All these are essen-
tially specific diseases ; each of them is produced by a distinct subetance,
and each produces the same substance, and by a morbid process sepa-
rates it from the blood. In most of these, also, as well as in many
of which the causes are internal and less evident, the local phenomena
are preceded by some affection of the whole economy : the whole blood
seems diseased, and nearly every fimction and sensation is more or
less disturbed from its health ; the patient feels " ill all over," before
the local disease appears ; i. e. before the more distinct and specific
morbid process is manifest in the place of inoculation or in some other
part. Herein is a very general ground of distinction between the specific
and the simple or common diseases : in the latter, the local phenomena
precede the general or constitutional ; in the former, the order is reversed.
We might, indeed, expect tliis to be a constant difference between the two ;
and perhaps it is so ; for though many exceptions to any rule founded
on it might be adduced, yet these may be ascribed to the unavoidable
sources of fallacy in our observations. Thus, every severe injury, every
iong-continued irritation, excites at once both local and general disease ;
AND 8PE0IFI0 DISEASES. 807
iuid the latter may be evident before the former, and may not only modify
it, but may seem to produce it. On the other hand, the insertion of
certain specific poisons, e. g. that of the venom of a serpent or an insect,
gires rise so rapidly to specific local disease that this seems to precede all
eonstitational afiection.
Notwithstanding such exceptions as these are, or seem to bo, this con-
trast between specific and common diseases, in regard to the order in
which the local and the constitutional symptoms arise, is so usual that
the terms specific and constitutional are often employed as convertible
terms in relation to disease. But this is not convenient ; for some specific
diseases are, or become, local ; and some constitutional diseases are not
specific.
8. A character very generally observed in specific diseases is an ap-
parent want of proportion between the cause and the efiect. In com-
mon disease, one might say that, on the whole, the quantity of local dis-
ease is in direct proportion to the cause exciting it, — whether violent
injury, heat, poison, or any other. Numerous exceptions might be
found, but this is, on the whole, the rule."*" In specific diseases there is
no appearance of such a rule : we cannot doubt its existence, but it is
lost sight of. Thus, in small-pox, measles, hydrophobia, or syphilis,
the severity of the disease is not, evidently, proportionate to the cause
applied: a minimum of inoculated virus engenders as vast a disease as
any larger quantity might.
4. I have said that there is generally a correspondence between the local
and the constitutional characters of a specific disease: but this is only in
respect of quality: in respect of quantity there is often such a want of
correspondence between the two as we rarely or never see in common
diseases. In general, the amount of common inflammatory fever after an
operation bears a direct proportion to the injury, and the amount of hec-
tic fever to the quantity of local disease (here, again, are numerous ex-
ceptions, but this is the rule) ; but in specific diseases it is far other-
wise. In syphilis and cancer, the severest defects or disturbances in
the whole economy may co-exist with the smallest amounts of specific
local disease; and, as Dr. Robert Williamsf has well said, "It may be
laid down as a general law, that when a morbid poison acts with its
greatest intensity, and produces its severest forms of disease, fewer
traces of organic alterations of structure will be found than when the
disorder has been of a milder character.*'
5. To specific diseases belong all that was said, in former Lectures
* I am tempted to say here, that in patliology, we must admit the existence of many
rules or laws the apparent exceptions to which are more numerous than the plain exam-
ples of them. This, however, is not enough to invalidate the truth of the laws ; it could
scarcely be otherwise in the case of laws, the exact observance of which requires the con-
currence of so many conditions as are engaged in nearly all the phenomena studied in
pathology.
t Elements of Medicine, vol. i. p. 12.
808 DISTINCTIONS BETWBBN OOllMON
(p. 27, e. 8.), of the symmetrical diseases, and of seats of election: mieii
phenomena occur in degenerations, but, I think, in no common diseaan.
6. The local process of a specific disease of nutrition is less apt than
that of a common one to be nearly limited to the area in which, in the
first instance, the cause of disease was applied. Specific diseases tre
peculiarly prone to spread, that is, to extend their area« They also,
among the diseases of nutrition, are alone capable of being erratic, i e.
of disappearing from the part in which they were first manifest, while
extending thence through other parts continuous with it ; and they alone
are capable of metastasis, t. e. of suddenly ceasing in one locality, and
manifesting themselves, with similar local phenomena, in another.
7. In all the particulars mentioned in the last preceding, and in sonie
of the earlier paragraphs, specific diseases manifest a peculiar charae*
ter in that they seem capable of self-augmentation ; no evident fredi
cause is applied, and yet the disease increases: witness the seemingly
spontaneous increase of manifest local disease in secondary and tertiaiy
syphilis, or in the increasing eruption of eczema or of herpes, or tl»
extension of a carbuncle, or the multiplication of secondary cancers.
8. Specific diseases alone are capable of transformation or metamcff-
phosis. As we watch a common disease, its changes seem to be onlj
those of degree; it appears increasing or declining, but is always the
same and a continuous disease. But in many specific diseases we see
changes in quality or kind, as well as in quantity. In syphilis, fbr
example, a long series of diseases may occur as the successive conse-
quences of one primary disease different from them all. They are all,
in one sense, the same disease, as having a single origin : but it is •
disease susceptible of change in so far as it manifests itself, at different
times, not only in different parts, but in different forms in each, and in
forms which are not wholly determined by the nature of the tissue
affected. The successive phenomena of measles, scarlet fever, and
many others, may, I think, be similarly expressed as metamorphoses or
transformations of disease.
9. A similar transformation of specific diseases may take place in
their transference from one person to another, whether by inheritance,*
or by infection, or contagion. A parent with one form of seoondaiy
syphilis may have a child with another form ; the child of a parent wA
scirrhous cancer may have an epithelial, a colloid, or a medullary can-
cer : the inoculation of several persons with the matter from one primary
syphilitic sore may produce different forms of the primary disease and
different consecutive phenomena; the same contagion of small-pox,
measles, or scarlet fever may produce in different subjects all the modi-
fications of which those diseases are severally capable ; the puerperal
* It might seem as if none but specific diseases could be hereditary; but many tumors
are so which we cannot well call specific: such as tlie cutaneous cysts or wens, and frtty
and cartilaginous tumors.
AND 6PB0IFI0 DISEASES. 809
J or the patient who has sustained a severe accidental or surgical
injury, may modify, or, as it were, color with the peculiarities of her
own condition, whatever epidemic or other zymotic disease she may
inenr.*
10. Lastly, time is a peculiarly important condition in many of the
qiecifio diseases. If we except the period of calm or incubation, which
uso^y occurs between the infliction of an injury and the beginning of
an evident reparative process, a period of which the length is, in general,
proportionate to the severity of the injury, there are few of the events
<if common diseases that are periodic or measurable in time ; there are
none that are regularly intermittent or remittent; none that can be
compared, for regularity, with the set tunes of latency of the morbid
poiaona of the eruptive fevers, or the periods in which they run their
course, or change their plan or chief place of action. Neither are there,
in common diseases, any periods of latency so long as those which elapse
between the application of the specific cause, and the appearance of
its specific efiect in the eruptive fevers, tetanus, or hydrophobia.
Such, briefly, are the chief general characters of the diseases which
are commonly named specific, or described as having something specific
in their action. In some of them, chiefly such as depend on distinct
morbid poisons, whether miasma, or virus, or matter of contagion, all
these characters may be observed ; and these are the best types of the
dasB. In others, part only of the same characters concur. I do not
pretend to define the exact boundary of what should be called specific,
and what common, in diseases; but it seems reasonable that any disease,
in which the majority of the characters just enumerated are found,
should be studied as one of the class, and that its phenomena should be
interpreted, if possible, by the rules, or by the theory, derived from the
■lore typical members of the same class.
The theory of specific diseases, in its most general terms, is, that
each of them depends on a definite and specific morbid condition of the
blood ; that the local process in which each is manifested is due to the
disorder produced by the morbid blood in the nutrition of one or more
tissaes ; and that, generally, this disorder is attended with the accumu-
lation, and leads to the discharge, or transformation, of some morbid
conistituents of the blood in the disordered part. It is held, also, that
in some specific diseases, the morbid condition of the blood consists in
undue proportions of one or more of its normal constituents ; and that
in others, some new morbid substance is added to or formed in the blood.
In either case, the theory is, that the phenomena of each specific disease
depend chiefly, and in the first instance, on certain corresponding
specific materials in the blood : and that if characteristic morbid struo-
* See Carpenter; Br. and For. Med.-Chir. Review, Jan. 1853, quoting from Simpson, in
Uoothly Joom. of Med. Sc. vol. xi. and xiii.
310 THEOBY OF SPECIFIC DISEASES.
tures be formed in the local process, they are organs in which thew
morbid materials are incorporated.
Now in regard to certain diseases, such as some of those that can be
communicated by inoculation, these terms are scarcely theoretical ; they
may rather be taken as the simplest expressions of facts. For example
(as I have already said, p. 283), in either syphilis, vaccinia, glanders, or
small-pox, especially when produced by inoculation, we have demonstra-
tion (1) of a morbid condition of the blood ; (2) of the definite and
specific nature of that condition, in that it is, and may be at will, pro-
duced by the introduction of a definite substance into the blood, and
manifests itself in a local disease which, within certain limits, has (xm-
stant characters ; and (3) of the same substance being accumulated and
discharged, or for a time incorporated in the morbid structures, at the
seat of the local disease. And it seems important to mark, that all
which is thus seen in some specific diseases, and is assumed for the ex-
planation of others, is consistent with facts of physiology ; especially
with those referred to in a former Lecture (p. 33, e. s.), as eyidencea,
that certain normal organs of the body are formed in consequence of the
presence of materials in the blood, which in relation to them, might be
called specific, and which they, in their formation, take from the blood
and incorporate in their own structures.*
The proof of the theory of specific diseases is scarcely less complete
for all thoso that are infectious or contagious, but cannot be commmii-
catcd by inoculation — such as typhus, measles, erysipelas ; and scarcely
less for those which are neither infectious nor contagious, but depend,
like cholera and ague, on certain materials which are introduced into
the blood, and produce uniform results, though they are not proved
to exist in the products of the morbid processes. For other diseasee^
classed or usually regarded as specific, such as gout, rhetunatism, car-
buncle, boil, the various definite, but not communicable, cutaneous erup-
tions, hydrophobia, tetanus, and many more, the evidences of the theory
are less complete. Yet they seem not insufficient ; while we have, in
many of these aficctions, proofs of the accumulation and separation of
morbid substances at the seats of local disease, and while, in all, the
chief phenomena are in close conformity with those of the diseases which
are typically specific. Relying on the similarity of all members of the
group of specific diseases, on the sufficiency of the terms of the theory
* Abundant illustrations of the same general laws, of both healthy and morbid fonnalioo
of structures incorporating specific materials from the blood, are supplied by the action of
medicines whose operation ensues in only certain organs. Dr. Robert Williams (1. e. p. 8)
has justly said, "■ The general laws observable in the actions of morbid poisons are, for the
most part, precisely similar to those which govcni medicinal substances, or only differ cm •
few minor points.'' The subject is too extensive for discussion here. It is admirably
treated by Mr. Simon in his Lectures on Pathology ; the work, which, together with that of
Dr. Robert Williams, may be studied with more profit, in relation to all the subjects of thii
Lecture, than any I have yet read.
THSOBT OF SPECIFIC DISEASES. 811
or the expression of the facts concerning them all, and on the evidences
MKe or less complete which each of them supplies for its truth, we seem
■tified in adopting the same theory for them all.
Bat now, if we may hold this theory to be true for some specific
Bnases, and not unreasonable for the rest, let us see how, in its terms,
ra can explain or express the chief characters of these diseases ; such as
kair periodicity, metastases, and metamorphoses, the apparent increase
i the specific substance in the blood, and the others just enumerated.
Us may be done while tracing the probable history, or, as I would call
i^the life, of the morbid material in the blood, and in the tissues. "*"
^lecific morbid materials, or at least their chief constituents, may
nter the body from without, by inoculation, contagion, or infection ; or
Ikj may be formed in the blood, or added to it, within the body : in
«fker words, some morbid materials are inserted, others are inbred, in
iht blood ; with some, probably, both modes of introduction are possible.
Doubtless, an important difference is thus marked between two chief
pwps of the specific diseases : but it is not within my present purpose
to dwell on it ; for only one general history can as yet be written for the
vkole class of morbid materials on which the specific diseases depend ;
ad, although this may be best drawn from the instances of those that
lie derived from without, t. e. from such as are called morbid poisons,
)et it would probably be as true, in all essential features, for those that
lie inbred.
When a morbid poison is inoculated, — ^for example, when the matter
ftom a syphilitic sore, or from a vaccine vesicle, is inserted in the skin,
—it produces a specific effect both on the tissue at the place of inser-
tion, and on the blood, as soon as it, or any part of it is absorbed ; in
other words, it produces both a local and a constitutional change ; and
ia both these effects its history must be traced.
L First, respecting the local change : of which, with another design,
I bive already spoken (p. 284). It is not proved by anything that can
be Been immediately, or even within one or two days after the inocula-
tifliL The place of inoculation remains, for a time, apparently unaffected :
ttd yet that a peculiar change is being wrought in it is clear, for it
praently becomes the seat of specific disease, the materials of which
Aease are supplied by blood that nourishes healthily all other parts,
€f€& such parts as may have received common injuries at or near the
tifte of the inoculation. The inoculated part, therefore, is not merely
bjored, but is peculiarly altered in its relation to the blood, which now
Boorishes it differently from all the rest of the body. The change of
tbe blood is proved, if not by general febrile or other disturbance, yet
* SeTeml of the characters of specific diseases are already explained, in the terms of this
Atorj, in the earlier Lectures : naraely, their specific forms and construction (pp. 33, 87,
k) ; gjminetrj and seats of electioo OPP- 27, 29, 283, e. s.) extension and errantry (p. 29,
S12 HISTOBT OF MOBBID MATBBIA£8
by the specific character of the presently ensuing disease, and by tbe
consecutive secondary disease, or by the consecutiye immunity fron
later disease of the same kind.
If further proof be needed of the specific local change produced in
the inoculated part, it may be furnished by the analogy of the more
visible effects of certain animal poisons, — such as those of yenomooB
serpents and insects. None of these appear to be simple irritants; the
consequences of their insertion are not like simple inflammations^ but are
peculiar, and constant in their peculiarities. The bite of a bug ori
flea will not, I hope, be thought too trivial for an illustration.
In less than a minute after the bite, the bitten part begins to itdi;
and quickly after this, a wheal or circumscribed pale swelling, with i
nearly level surface and a defined border, gradually rises and extends in
the skin. It seems to be produced by an oedema of a small portion of
the cutis at and around the bite ; it is not a simple inflammatory swelling;
it is, from the first, paler than the surrounding skin, which may be
healthy or slightly reddened by afflux of blood : and the contrast between
them becomes more striking, as the surrounding skin becomes graduallj
redder, as if with a more augmented fulness of the bloodvessels. Thm,
for some minutes, the wheal appears raised on a more general, and len
defined, vascular swelling of the surrounding and subjacent tissues ; bnt
after these minutes, and as the itching subsides, the wheal, or paler
swelling becomes less defined, and the more general swelling appetn
gradually to encroach on it and involve it. Then all subsides : but only
for a time ; for in about twenty-four hours a papule, or some form of
secondary inflammation appears, with renewed itching, at the seat of the
puncture, and this after one, two, or sometimes more days, gradually
subsides.*
Now, the first pale and circumscribed swelling at any of these bites
may serve to illustrate the immediate effects of a morbid poison on the
tissues at and around the seat of inoculation. In the area of such a
swelling the tissues are, by the direct contact and influence of the venom,
altered in their nutritive relation to the blood. So, I believe, imme-
diately after the insertion of syphilitic, vaccine, or other virus, there
ensues a corresponding specific alteration of those parts of the 8a^
roimding tissues which afterwards become seats of the specific local
disease.f
* Some persons are so happily constituted, that they do not thus, or with any other dk>
comfort, suffer the consequence of insect-hites ; but I think the description I have girea
will be found generally true for cases in which the bitten part is left undisturbed. The
fortunate exempt may illustrate the rarer exceptions from the usual influence of the seTerer
morbid poisons.
t Tlie direct influence of animal poisons on the tissues appears to be well shown io tbe
effects of the bites of the viper and rattlesnake. Sir B. C. Brodie particularly noticed this
in a man bitten by a rattlesnake (Lectures on Pathology and Surgery, p. 345). The primaiy
local, though widely extended, odect of the poison was a sloughing of the cellular mem-
IV THB BLOOD AKD TISSUES. 818
I will not Tentore to say that the secondary inflammation, which usually
ippean on the day after any of these bites, is to be ascribed in some
netsore to an influence exercised by the virus on the blood ; though,
indeed, this will not^seem impossible to those who are considerate of the
eSfict of the minutest portion of vaccine virus, and of the intense con-
ititetional disturbanoe excited by the other venoms. But, whatever be
thought on this point, the occurrence of a new and different inflamma-
tioii in the bitten part proves that it did not return to perfect health
iben its first affection subsided ; it proves that some altered material of
tlie virus, or some changing trace ofits effects upon the tissues, remained,
altering their relation to the blood, and making them alone, of all the
puts of the body, prone to specific disease. The bitten part thus, in
hi interval of apparent health, instructively illustrates the state of parts
ifter inoculation with syphilitic or vaccine virus. In them, as in it, we
moat suppose that some virus, or some specific effect produced by it
on the tissues, remains during all that period of latency, or incuba-
tion, as it is caUed, which intervenes between the inoculation and the
ifqiearance of the specific disease.
Whatever be the state thus indirectly induced in the inoculated or
bitten part, let it be noted as one constantly changing. The tissues of
the part, like the rest of the body, are engaged in the constant muta-
tioni of nutrition ; and the morbid material in the part is probably, like
every organic matter, in constant process of transformation. Some of
ike local phenomena of specific diseases indicate these progressive
changes in the part itself ; but they can scarcely be traced separately
from those that are occurring in the morbid material absorbed into the
blood.
The local and peculiar change produced by the direct effect of the
morbid poison is essential to the complete manifestation of some specific
diseases. In many others, as in typhus, variola, acute rheumatism, and
gout, the morbid condition of the blood is sufficient to determine the
local disease in tissues previously healthy. But it is, perhaps, true for
all, that the existence of some part whose nutrition is depressed, whether
through simple or specific injury, is very favorable to the manifestation
of the constitutional disease (see p. 284). Thus, I shall have to mention
eases of cancer in which the constitutional condition, or diathesis, seems
to have been latent till some local injury brought a certain part into a
state apt for the cancerous growth, — ^the diathesis, as one may say, waited
for the necessary local condition. In like manner, cases sometimes occur
bnme, which began ** immediately after the injury was received." The poison " seemed to
operate on the cellular membrane, neither in the direction of the nerves, nor in that of the
absorbents, nor in that of the bloodvessels." His account has been recently confirmed in a
more quickly (atal case. Many years ago, one of my brethren was stimg by a Weever-fish
(TrachiDus Draco) ; and I remember that next day, though no severe inflammation had
intervened, there was a little black slough at the puncture, as if the venom had completely
killed a piece of the skin.
314 HISTORY OF MOBBIB MATBBIAL8
in which constitntional syphilis is justly presumed to exist, but in wludi
it has no local manifestation till some part is appropriated for it by the
effects of injury. I know a gentleman, who, for not less than five
years after a syphilitic affection of the testicle, had no sign of syphilk,
except that of generally feeble health ; but he accidentally struck hia
nose severely, and at once a well-marked syphilitic disease of its bones
ensued. In another case, syphilitic disease of the skull followed •&
injury of the head. In similar cases, ulcers like those of tertiaij
syphilis have appcaread in hesiling operation-wounds. I lately saw i
gentleman who had long suffered with diabetes, a condition with which,
as is well known, boils often coincide. He, however, had none till he
accidentally struck his leg, and the injury was quickly followed by a sno-
cession of more than twenty boils near the injured part. And, in like
manner, as I have stated in a former Lecture (p. 285), even variola ud
measles may have their intensest local manifestations in injured parts.
I need not dwell on the importance of cases such as these, for caution
against supposing that the diseases which seem to originate in local injnij
are only local processes. The most intense constitutional affections may
appear, almost irrespective of locality, able to manifest themselves in
nearly every part ; but the less intense may abide unobserved, so long as
all the tissues are being maintained without external hindrance or inte^
ferencc ; they may be able to manifest themselves only in some part whose
normal power of maintenance is disturbed by injury or other disease. It
may, generally also, be noticed that the more intense the constitutional
affection, and the less the need for preparation of a locality for its mani-
festation, the less tenacious is it of its primary seat. Contrast, for
example, in this respect, the fugacity of acute rheumatism or gout with the
tenacity of chronic rheumatism in some locality of old disease or injury.*
II. Respecting, secondly, the changes which a morbid material, inocu-
lated and absorbed, may undergo in the blood, these may be enumerated
as the chief; — increase, transformation, combination, and separation or
excretion. Here, again, one assumes for an example such a morbid mi-
tcrial as may be inoculated ; but it will be plain that most of what la
said, in the following illustrations, might also be said of those that are
otherwise introduced into the blood ; and further, that the particulars of
the life of these morbid materials are generally consistent with those of
ordinary constituents of the blood.
(a) The increase of the morbid material in the blood is illustrated in
syphilis, small-pox, vaccinia, glanders. In any of these, the inoculation
of the minutest portion of the virus is followed by the formation of one
or more suppurating structures, from which virus, similarly and equally
* Dr. Carpenter (1. c.) has clearly traced that epidemic and other zymotic influences betr,
with peciihar force, on those in wlioso blood there is " an accumulation of disintegiatiog
azotized compounds in a state of change.*' Is it not a similar degenerate condition wliich
makes an injured part peculiarly amenable to the influence of specific morbid materials in
the blood ?
IH THI BLOOD AND TISSUES. 816
8 produced in million-fold quantity. So, the matter of any con-
orldng in one person may render his exhalation capable of simi-
9cting a thousand others.
ncrease is thus evident. The effect of the inoculated morbid
lay be compared with that of a ferment introduced into some
compound, in some of the materials of which it excites such
MB issue in the production of material like itself. What are the
b of the blood tlius changed and converted to the likeness of the
poison we cannot tell. The observations of Dr. Carpenter,'*'
how peculiarly liable to all contagious and other zymotic in-
they are whose blood is surcharged with decomposing azotized
Ib, may well lead us to believe that it is among these materials
ny of the morbid poisons find the means of their increase. And,
Simonf argues, it seems nearly sure that certain of these poisons
increase, so convert some material of the blood, that they wholly
it, and leave the blood for a long time, or for life, incapable of
pun affected by the same morbid poison.
Qcrease of the morbid material, however effected, explains these
nrs of specific diseases : — ^the apparent disproportion between the
cause and its effect (p. 307); the want of correspondence, in
of quantity, between the local and the constitutional phenomena
; the seeming capacity of self-augmentation (p. 308).
le transformation of a morbid material is indicated by the diver-
khe successive manifestations of a single and continuous specific
Thus, in syphilis, the primary disease, if left to its unhindered
18 followed, with general regularity, by a series of secondary and
diseases. The terms often used would imply that these diseases
to a morbid poison which is, all along, one and the same. But,
of causes should be manifested in identity of effects ; the suc-
of morbid processes proves a succession of changes, either in the
oison, or in the patient. They may be in the latter ; but, regu-
ley are in the former: for, on the whole, the succession of secon-
d tertiary syphilitic diseases is uniform in even a great variety of
u We may, therefore, believe that the regular syphilitic pheno-
vpeinA on the transformation of the morbid poison : their irregu-
on the peculiarities of the patient, whether natural or acquired
eatment.
aransformation here assumed is self-probable, seeing the analogy
mve transformations in all organic living materials. It is nearly
by the different properties, in regard to conmiunicability, of the
ic poison at different periods: in the primary disease conmiuni-
f inoculation, but not through the maternal blood to the foetus ; in
xidary, having these relations reversed ; in the tertiary, not at all
Dieable. In like manner, such facts as that the material found
* Loc oiL p. 159. t Lectures on Surgical Plithologj, p. 262.
816 HI8T0BT OF MORBID MATBRIAL8
in the vaccine vesicle, on the eighth day, is better for fresh Yaccinatkni
than that taken earlier or later, prove successive transformationB,— pe*
riods, we may say, of development, maturity, and d^eneration, in the
material of the virus.
Many similar phenomena of transformations in the morbid poim
may be cited ; and if it may be accepted as a general occurrence, it iril
explain many of the phenomena of specific diseases. The period of inei'
bation or latency of a disease (p. 809) may correspond with the tnmi-
formation preceding the effective state of the morbid poison, with ill
periods of development. The prodromata, the precursive constitntioiial
affections, and the successive stages of the disease, indicate the conti-
nuous transformations and varying influences of the same: just as ereij
difference of organic construction indicates a difference in the yet uk*
formed materials used in it. The increasing disturbance of the generd
health probably implies that the morbid poison increases while being
transformed; that it grows with its development. The periodidty of lU
these events (page 309) is a sign that the transformations of morbid poi-
sons, like those of all other materials in the living body, are, in ordiniiy
circumstances, accomplished in definite times. The sequelsB of specififi
diseases indicate yet further transformations, or, more probably, that tlM
changes of the morbid poison have left the blood in a morbid state, throng
the exhaustion of some of its natural constituents, or through the pr^
sence of some complemental material.
(c) The combination of a morbid poison with one or more of the normal
materials of the blood is indicated by the fact, that when the same sp^
cific disease, produced even by the inoculation of the same matter, affects
many persons, it may present in each of them certain peculiar features.
And these personal peculiarities, as they might be called, indicate modi-
fied qualities of the disease ; not merely such differences of quantity as
might be explained by assuming that each person has, in his blood, a dif-
ferent quantity of such material as may be convertible into the morbid
poison. Difference of quantity may explain (as Mr. Simon and Dr. Ca^
penter have shown) difference of intensity of specific disease, and diffe-
rence of liability to epidemic influence; but it does not explain the
varied method of the same disease in different persons. For this, I be-
lieve, we must assume that the specific material of each disease may be,
in some measure, modified by its combination with one or more of those
normal materials of the blood which have, in each person, a peculiar or
personal character (see p. 26, e. s.)
By such combination, we may best explain those characters of specific
disease, which appear in its changes in transmission from one person to
another (page 308) : such as the varieties of syphilitic sores, and the
varieties of their consequences in different persons inoculated from the
same source ; the change in the form of secondary syphilis or of cancer
in transmission from parent to offspring ; the several peculiarities in the
IH THB BLOOD AKD TISSUES. 817
molts of the same miasm when affecting ordinary persons, or puerperal
mmen, or those who have snryived injuries.
A remarkable instance, exemplifying, I think, as well the changes in
die morbid poison itself, as its various effects on different persons, has
been told me by my friend Mr. Huxley. One of the crew of H. M. S.
Battlesnake, after slightly wounding his hand with a beef-bone, had
l^raration of the axillary lymphatic glands, with which typhoid symp-
tOBS and delirium were associated, and proved fatal. His illness began
dM day after the ship left Sydney, where all the crew had been remar-
hUy healthy. A few days after his death, the sailor who washed his
cbdieB had similar symptoms of disease in the axilla, and, for four or
ht months, he suffered with sloughings of portions of the cellular tissue
of the axilla, arm, and trunk on the same side. Near the same time, a
flird sailor had diffuse inflammation and sloughing in the axilla; and
■fier this ^Hhe disease ran, in various forms, through the ship's com-
piny, between thirty and forty of whom were sometimes on the sick-list
•ft once." Some had diffuse cellular inflammation ; some had inflamma-
tka of the lymphatic glands of the head, axilla, or lower extremities;
one had severe idiopathic erysipelas of the head and neck ; another had
pUegmonoos erysipelas of the hand and arm after an accidental wound ;
odiers had low fever with or without enlargement of glands. " Finally
&e disease took the form of mumps, which affected almost everybody on
board." The epidemic lasted from May to July. The ship was at sea
the whole time, and in the greater part of it, in the intense cold of a
Nmthem winter.
(d) The Beparation of the material of a specific disease may, probably,
be accomplished in many different ways, and may be regarded as the
inal purpose (if we may venture to trace one) of the greater part of the
Borbid process. It is evident in the inoculable products of sores and
aostoles ; in the infectious exhalations of the skin, pulmonary, and other
mrfaces in the exanthcmatous and other fevers ; in the deposits in and
lear gouty joints. Analogy with these cases makes it, also, probable that
the specific materials of several other diseases are separated from the
blood accumulated at the seats of the local morbid process ; whence, if
no organisms incorporating them be constructed, they may be reabsorbed
ifter transformation. And it is nearly certain that the materials of
most specific diseases may be excreted with the natural evacuations in
Lhe course of the disease, and this, either in their mature state, or after
transformation, or in combination with the constituents of specific medi-
anes.
The results of such separation or excretion are, also, various. Some-
ames, it seems as if the whole of the morbid material were (after various
Eransformations) removed, and the blood left healthy: as in small-pox,
raccinia, cured primary syphilis. Sometimes, part of the morbid mate-
rial, transformed or combined, so as to be incapable of excretion, remains
in the blood, and produces secondary phenomena or sequel® of the dis-
818 GSNBBAL 0HARA0TEB8 0¥ TUMORS.
ease. Sometimes, the production of the morbid material contimus,
withstanding the separation of what is already formed: as in the n
of the cancerous diathesis during the growth of cancers. Generany,!
whatever manner the separation be accomplished, it is attended by
disturbance of the natural functions of parts, that serious disetie
superadded to that which is the more direct consequence of the
of the morbid material in the blood. And lastly, a local disease
owes its origin, and for a time, its maintenance, to a specific morbid
dition of the blood, may persist after that condition has ceased; de
blood may regain its health by the separation of the morbid matemi,
but the part diseased in the process of separation may so contimie.
Now, however, the disease may be wholly local, and curable by lool
treatment.
Thus may the theory of specific diseases be applied in explanation of
their phenomena. I will only add that in assimiing all this of the
changes occurring in morbid materials in the blood, we really assniM
little more than we believe of the organizable materials introduced, ti
nutriment, into the blood. If we could trace these, in their chango,
first in the chyle and blood, and then in some complex tissue, then in
the lymph and blood again, and again through the tissues of some
excretory gland, we should trace a career of changes not less numeroos,
not less definite in method and in time, not less influential in the eco-
nomy, than those which I have assumed for morbid materials in the blood.
Only, the increase of the morbid material, and the apparent indepen-
dence of its changes, are not imitated in the normal events of life.
LECTURE XXL
CLASSIFICATION OF TUMORS.
The class of diseases which includes the tumors may be reckoned as i
part of the great division named Hypertrophies or Overgrowths. All
its members consist in additions to the organized materials of the body,
and appear to be expressions of a morbid excess of formative force ; but,
in the case of each hypertrophy, the mode is peculiar in which this excess
is manifested. If wc compare any tumor with one of the hypertrophies
that arc least morbid, with one of those, for instance, in which the ex-
cessive growth is adapted to some emergency of disease, as an hyper-
trophy of the heart is adapted to some emergency of the circulation, we
shall, I believe, always see between them this chief difference : that, to
whatever extent the adapted hypertrophy may proceed, the overgroini
eiHlRAL CHARACTERS OF TUMORS. 819
tains itself in the normal type of shape and structure ; while a
ia essentiallj a deviation from the normal type of the hody in
it grows, and, in general, the longer it exists the wider is the de-
A striking illustration of this contrast may be found in some
of fibrous tumors that grow in the cavity of the uterus.*
tumor may resemble in its tissues the substance of the uterus itself,
well-formed muscular and fibrous tissues ; and, so far as the struc-
formed in excess are concerned, we might regard the tumor as the
idt of an hypertrophy not essentially different from that which, at the
me time and rate, may take place in the uterine walls around it. But
A enential difference is in this : the uterus, in its growth around the
■lor, maintains a normal type, though excited to its growth, if we may
B qieak, by an abnormal stimulus : it exactly imitates, in vascularity and
■Bcular development, the pregnant uterus, and may even acquire the
le power ; and at length, by contractions, like those of parturition, may
■pel the tumor, spontaneously separated. But the tumor imitates in its
powth no natural shape or construction : the longer it continues the
pater is its deformity. Neither may we overlook the contrast in re-
feet of purpose, or adaptation to the general welfare of the body, which
las manifest in the increase of the uterus as it is improbable in that of
m tumor.
Herein we seem to discern an essential difference between the over-
powths of tumors, and those accomplished by any exercise of the nor-
Ml power of nutrition in a part. This power, capable of augmented
BDercise in any emergency, is yet not a mere capacity of production ;
leither is it dependent upon circumstances for the fashion of its products;
Amtical with that which effected the development of the germ, it is
Mpially bound to conformity with the proper type of the part or species
b which it is exercised.
An equal contrast may, in general, be drawn between the class of
leases that includes tumors, and all the others that issue in a morbid
eieess of nutritive formation. We may take, as the example of these,
^ inflammatory diseases attended with exudation, and say (reserving
Mam conditionsf) that in these there is an excessive exercise of for-
Mive force, an hypertrophy. But between such diseases and tumors wo
Ui rarely fail to observe the following differences : — 1st. The accumu-
lition and increase of lymph in inflammation appears chiefly due to the
Aorbid state of the parts at or adjacent to the place of exudation. We
kre, I think, no evidence that the lymph of inflammation increases, by
iiy inherent force, any attraction of self-organizing matter, or any
ndtipUeation of its own cells ; but the increase of all, or nearly all,
* Such as (e.g.) No. 2682 in the G>Ilege Museum. Respecting the conditions in which
^ ehtnges in the uterus here described are likely to occur, see Rokitansky, Patliologische
Asaioiiiie, iiL 546.
t See p. 277.
820 GENBRAL CHARACTERS OF ZUMOEfl.
tumors, is '^ of themselves :" they grow as part of the body, but by ih«
own inherent force, and depend on the surrounding parts for little mon
than the supply of blood, from which they may appropriate materiak
A tumor, therefore, as a general rule, increases constantly ; an iDfla»
matory exudation generally increases only so long as the disease in tke
adjacent parts continues.
2d. The materials severally produced in excess, in these two cases, haTB
different capacities of development. The inflammatory ezadatioDy ia
whatever part it lies, has scarcely more than the single capacity to fon,
in the first instance, fibro-cellular or fibrous tissue : the material that
begins or is added to a tumor may, indeed, assume either of these fonu^
but it may assume any one of several other forms.
But, 3dly, the most striking contrast is in the events sabsequent to
this first organizing of the two materials. The later course of organiied
inflammatory exudations, like that of the organized material for repur
after injuries, is usually one of constant approximation to the healthj
state. As newly-formed parts, they gradually assimilate themselves to
the shape and purpose, if not to the tissue, of the parts among whieb
they lie ; or they are apt to waste, degenerate, and be removed. Their
changes tend ever toward a better state ; so that, in the whole coarse of
exudative inflammatory diseases, some can see nothing but an '^ effort of
nature" to avert or repair some greater evil.* It is very different with
the class of diseases to which tumors belong : it is in their very nature to
proceed to further and further deviation from the proper type of the body.
The structure of tumors may indeed be like that of some of the natonl
parts; it may be identical with that of the part in which they lie: in
this respect they may be called homologous ; but, considered in their
life, they are not so ; for, commonly, they are growing while the tissoeB
far and near around them arc only maintaining their integrity, or are
even degenerating, or yielding themselves to the anormal growth.
I think that it is only in the consideration of this activity and partial
independence of the life of tumors, and of the diseases allied to then,
that we shall ever discern their true nature. We too much limit the
grounds of pathology when, examining a tumor after removal, we onlj
now compare it with the natural tissues. The knowledge of all its present
properties may leave us ignorant of the property which it alone, of all
the components of the body, had some time ago — the property of grow-
ing. And so, if we can ever attain the knowledge of the origin of a
tumor, it may avail little, unless it supply also the explanation of its
progress. If, for example, what is very improbable could be proved,
namely, that tumors have their origin in the organization of extravasated
blood, or of an inflammatory exudation, still this greater problem would
• There are, indeed, cases in which organized lymph and scars continue to grow; hoi
tliesc are quite exceptional, and are to be regarded as diseases of the same class as tumon,
peculiar only in respect of the materials in which they are manifested.
eiHBRAL OHARACTBBS OF TUMORS. 821
in nnsolyed : — How or why is it, that, in ordinary cases, these mate-
ttdSy when organized, gradually decrease, and assimilate themselves to
Be mdjacent parts ; while, in the assumed formation of tumors, they gra-
■tally increase, and pursue, in many cases, a peculiar method of develop-
ttnt and growth ? Why is it that, assuming even a similarity of origin,
ifte new-formed part manifests, in the one class of cases, a continuous
^(tadency towards conformity with the type of the hody ; in the other, a
(fantinaons deviation from it in shape and volume, if not in texture?
jKhr is it that, to take an extreme case, we can ever find, as in a speci-
Ikn* at St. George's Hospital, fatty tumors of considerahle size in the
iteentery of a patient from whom, in the extremest emaciation of
jlidiiss, nearly all the natural fat was removed ; or, as in a case related
%f Schah,t huge lumps of fat, on the head, throat, and chest of a man
iriuise abdomen and legs were extremely thin ?
I do not pretend to answer these questions ; but I think that in them
lithe touchstone by which we may tell the value of a pathology of this
peat class of diseases. It is not in the likeness or in the unlikeness to
^%t natural tissues that we can express the true nature of tumors : it is
; M enough to consider their anatomy ; their physiology, also, must be
Hodied: as dead masses, or as growths achieved, they may be called like
r unlike the rest of a part ; but, as things growing, they are unlike it.
h is, therefore, not enough to think of them as hypertrophies or over-
growths : they must be considered as parts overgrowing with appearance
•f inherent power, irrespective of the growing or maintenance of the
lest of the body, discordant from its normal type, and with no seeming
purpose.
To all this, I know, it may be objected that tumors, and other lik(>
growths, may cease to grow, or grow unequally, and yet are tumors still.
Bat this is only in appearance opposed to what I have said, which is no
more than that the best or only time, in which we may discern the true
dUerenoe of these from other growths, is the time of their active increase.
As we can have no complete idea of any living thing, unless it include
^ recognition of its origin, and of its passage through certain phases
of development and growth ; so must our thoughts of these abnormities
be imperfect and untrue, unless we have regard to their development, and
growth, and maintenance, as independent parts. But, indeed, the cessa-
tkm of growth in tumors and the allied diseases often affords evidences
rf their peculiar nature, confirmatory of that deduced from their increase.
Soch cessation may occur when they have attained a certain regular size :
tt in the painful subcutaneous tumors, the osseous tumors on the phalanges
rf great toes, and some others, which, perhaps always, cease to grow
when they have reached a limit of dimensions that appears as natural
wd constant for them as the average stature is for the individuals of any
• Y. 71, Museum of St. George's Hospital,
t Die Erkenntniss der Pseudoplasmen, p. 101. Wain. 1851.
21
822 GENERAL CHARACTERS OF TUXOBB.
species. Or, the cessation of growth may occur when the tumor degene-
rates or wastes ; as when a fibrous tumor calcifies, or when a mammaij
glandular tumor is absorbed. But it is to be observed that these eYento
are, or may be, as irrespective of the nutrition of all the rest of tbe
body, as the development and growth of the tumor were; and thit,
except in the comparatively rare event of the absorption of a tumor,
there is, in no case, an indication of return to the normal type or condi-
tion of the body: there is no improvement, as in the organized lympk
exuded in the inflammatory process, no adaptation to purpose, no assump-
tion of a more natural shape. In all these events, therefore, as well u
in their growth, the nearly independent nature of the tumor is shoim:
while forming part of the body, and borrowing from it the apparttu
and the materials necessary to its life, the tumor grows or maintMiw
itself, or degenerates, according to peculiar laws.
The characters of which I have been speaking belong to a larger nun-
ber of abnormities than are usually called tumors : they belong, indeed,
to a large class, of which tumors form one part or section, while the
other is composed of certain morbid enlargements of organs, by what is
regarded as merely hypertrophy ; such as that of the prostate, the thy
roid gland, and others.* Now the distinction between these two divisioni
of the class must, I believe, be an arbitrary one ; for the two are so little
unlike, that, really, it is in these hypertrophies of glands that we may
hope to find the truest guidance to an insight into the nature of tumon.
In speaking of cysts from the walls of which vascular growths may
spring and fill their cavities, I shall have to describe that these intrt-
cystic growths are, in their best state of structure, close imitations of
the gland in which they occur. In relation to tumors, the most inst^l^
tivo examples of this fact arc in the cystic tumors of the breast, of which
the general structure has been especially illustrated by Dr. Hodgkin and
Sir B. C. Brodie, and the microscopic characters by M. Lebert and Mr.
Bii'kett. Among these, a series of specimens in the Museum,f may illus-
trate every stage of the transition, from the simple cyst, to the cyst so
• The class may seem to include, also, those abnormal states of the foetus wliich are it*
tended with excessive growth or development of organs or members, yet cannot beascnbed
to a fusion of two germs : and, indeed, in the case of certain bony growths the line cannot
be drawn, without artifice, between monstrosities by excess and tumors (see Lecture XXVH)
But, in the large majority of cases, there are sufficient characters of distinction between them ;
for, 1st, the congenital excesses of development present a more complex structure, and are
more conformed to the plan and construction of the body, than anything that can be msoo*
ably called a tumor. And, if it be said that this higher organization is no more than is
consistent with the period of formation, which is in embryo-life, when the force of deTfr
lopmcnt is greatest, then, 2dly, we may note this difference ; that the congenital excesies
are usually limited for their increase to the perio<l of natural growth of the body. They
commonly cease to grow when or before the body lias attained its full stature : they coO'
form to its methods and times of development, growth, and decay.
t Mus. Coll. Surg., Nos. IGS, 109, 170, 172, &c.
eBVBRAL OHARAGTEBS OF TUMORS. 828
g^d substance as to form a solid tumor, — the chronic mam-
nammary glandular tumor. Now a near parallel with the history
ammary tumors is presented by the observations of Frerichs'*'
uukyt on the intra-cystic growths which occur within the sub-
enlarging thyroid glands, t. e. of increasing bronchoceles. In
ses of new-formed thyroid gland-tissue arc found imbedded
ed in fibro-cellular coverings or capsules, within the proper
Teased substance of the gland. In like manner, as Rokitansky
f it is not unusual in enlargements of the prostate gland, to find
uses of new structure imitating that of the prostate, which
led and incapsuled in the proper substance of the gland,
(and here is a closer contact between these hypertrophies and
liese growths of new gland-tissue may appear, not only in the
of the enlarging thyroid and prostate glands, but external to
led from the glands. Such outlying masses of thyroid gland
re near bronchoceles ; lying by them like the little spleens one
near the larger mass. Near the enlarged prostate, similar
ratlying masses of new substance, like tumors in their shape and
and like prostate gland in tissue, may be sometimes found. A
and remarkable specimen of the kind was sent to me by Mr.
It was taken from a man, 64 years old, who, for the last four
lis life, was unable to pass his urine without the help of the
de died with bronchitis ; and a tumor, measuring 2} inches
B found, as Mr. Wyman described it, " lying loose in the blad-
oonnected to it by a pedicle, moving on this like a hinge, and
3sed forwards, obstructing the orifice of the urethra." Now,
eneral aspect and in microscopic structure, this tumor is so
tion of enlarged prostate gland, that I know no character by
listinguish them.§
Bktion of these new-formed isolated portions of thyroid or prostate
o intimate, on the one side, to admitted tumors, such as the
ammary, and, on the other side, to the general hypertrophies
ands, that we cannot dissociate these diseases without great
jO nature. Clearly these are all essentially the same kind of
ret, to call them all "tumors" would be to do as much violence
nventional use of terms which have become not merely the
IS, but the guides, of our thoughts. The best course seems to
:e an arbitrary division of this group. In accordance, then, with
lition of custom, we may assign the name of tumors to such
3a]Iert- oder CoIIoidgeschwalste. Gottingen, 1847.
.tomie des Kropfes ; and Ueber die Cyste, in the Denkschr. der k. Akademie der
ten, Wien, 1849.
scimen is in the Museum of St. Bartholomew's Hospital A remarkable tumor
» kind, but imbedded in the substance of the prostate, is in the Museum of
ex Hospital.
mors will be further described in the twenty-eighth lecture.
324 DISTINCTIONS OF IKKOCBNT
examples of these morbid growths or growing parts, as, 1st, are iiolatrf
from the surrounding parts by distinct investing layers of tissue; m^' ^
2dly, though continuous with the natural parts, are abruptly
scribed in the greater part of their extent; or, 3dly, are formed of
materials infiltrated and growing in the interstices of natural parts.
If the group of what are to be called tumors may be thus inclosed,
may next proceed to divide it into smaller parts. And, first, it
proper to divide tumors according as they may be named inDooent
malignant. I would employ these terms stUI, because, though not frn
from objections, they imply a more natural and a less untrue divisNl
than any yet invented to replace them. The distinction between iniMh
cent and malignant tumors is probably one, not of mere visible stmetim^
but of origin and vital properties ; it is, therefore, less falsely expreocl
by terms implying quality of nature, than by such as refer to stmctvt
alone.
The chief distinctions are to be traced in certain characters which, m
the malignant tumors or cancers (for these terms are synonymous) an
superadded to those already cited as belonging to the whole class.
And, first, the intimate structure of malignant^umors is, usually, nol
like that of any of the full^ developed natural parts of the body, nor lib
that which is formed in a natural process of repair or degeneration.
Many of the cells of cancers, for example, may be somewhat lib
gland-cells or like epithelium-cells; yet a practised eye can distinguidi
them, even singly. And much more plainly their grouping distinguubi
them : they are heaped together disorderly, and seldom have any lobaltf
or laminar arrangement, such as exists in the natural glands and epi-
thelia, or in the innocent glandular or epithelial or epidermal tomofi
These innocent tumors are really imitations, so far as their structure is
concerned, of the natural parts ; and the existence of such imitatiou
in any tumors make the diversity — the heterology, as it is called— of
the malignant tumors, appear more evident.
Still, this rule of dissimilarity of structure in malignant tumora ii
only general. The other properties of malignancy may be sometimci
observed in tumors that have, apparently, the same structure as those tint
are generally innocent. I shall have to refer to cases of fibrous tomoil
which, in every respect of structure, were like common fibrous tumon,
and yet returned after removal, and ulcerated, with infection of adjacent
parts, and appeared in internal organs. These, with some others, mast
he regarded as malignant, though in structure resembling innocent
tumors and natural tissues. On the other hand there are some inno-
cent cartilaginous tumors, with structures as difierent from those that
exist in our natural tissues, as cancer-cells are from gland-cells or from
epithelial-cells. The two sets of cases, though both be exceptiooali
supply sufficient grounds for not preferring such terms as '^homologous**
AHD MALIGNANT TUMOBS. 825
■d ^beterologons" before "innocent" and "malignant," if the former
n maint, as they commonly are, to apply to the structure of the seve-
tal growths.
Secondly, malignant growths may have the character of infiltration;
u €n their elementary structures may be inserted, infiltrated, or difiused
in the interspaces and cavities of the tissues in which they lie. Thus, in
ili early state a malignant tumor may comprise, with its own proper
dsmentSy those of the organ in which it is formed; and it is only in its
later life that the elements of the tissue or organ disappear from it,
gradually degenerating and being absorbed, or, possibly, yielding them-
adres as materials for its growth.'^
Thus, a hard cancer of the mammary gland includes in its mass a
fart, or even the whole, of the gland itself, as if there were only a
aonTereion of the gland-tissue: and one may find, within the very sub-
atance of the cancer, the remains of the lactiferous tubes involved in it,
and, with the microscope, may trace in it the fibro-cellular tissue that
separated the gland-lobes, and the degenerate elements of the epithelial
contents of the tubes and acini. But among all these lie the proper cells
of the cancerous growth, and these usually increase while the original
atnictares of the gland decrease. So, too, in medullary cancerous disease
of the uterus, the uterus itself, or part of it, is in the tumor, and gra-
dually wastes, while the medullary matter, difiused or infiltrated in it,
v growing.
The malignant growths may, I say, thus appear as infiltrations ; but
tliey are not always so. Thus, though the hard cancer of the breast is,
commonly or always, an infiltration of cancerous substance in and among
the proper structures of the gland, yet the hard cancer of the bones is
often a distinct tumor, such as has no mixture of bone in it, but may
be enucleated from the cavity or shell of bone in which it lies. So, too,
ibile the medullary cancer of the uterus plainly consists in an infiltra-
tion or insertion of new material in the substance of the organ, that of
the breast is usually a separate tumor, and altogether discontinuous
{rom the surrounding parts.f
Many other instances of similar contrast might be cited; still the fact
tkt their elementary structures may be thus infiltrated in the tissues
thej tffect is a characteristic feature of malignant tumors. I think it
is rarely imitated in cases of innocent tumors.
3d. It is, also, generally characteristic of malignant tumors that
tl»y have a peculiar tendency to ulcerate, their ulceration being com-
* See, on this latMnentioned point, Rokitansky, Pathol. Anatomie, i. 121. If, in such a
^1 the remoTal of the original textures he quicker or more considerable than the produc-
°<)Q of the new morbid substance, there may be no swelling or visible tumor : yet, since
^ new material increases, the essential character of a growth is observed. Such growth
^'^t swelling is often noticed in hard cancers of the breast and of the bones.
t Kos. 2787, 2796, and others in the College Museum ; and Nos. 15 in Ser. 32, and 28 in
. ' 35, or that of St Bartholomew's, illustrate these contrasts. On the difference between
^^t^akm and otUgnwihtf see p. ddi.
826 DISTINCTIONS OF INNOCBNT
monly preceded by softening. One can, indeed, in this particular, onlj
observe a graduated difference between the innocent and the malignant
diseases ; for certain innocent tumors, if they grow very rapidly, are apt
very rapidly to decay ; and they may suppurate and discharge their ichor
and debris with foul and dangerous ulceration. Thus th6 quickly-grow-
ing cartilaginous tumors may imitate, in these respects, malignant growtb;
so may large fibrous tumors when they soften and decay. Or, again,
when an innocent tumor grows more rapidly than the parts over it can
yield, they may waste and ulcerate, and allow it to protrude ; and it
may now itself ulcerate and look very like malignant disease. This
may be seen in the protruding fibrous tumors that ulcerate and bleed;
or, in a more striking manner, in the protruding vascular growths tliat
have sprung up in the cystic tumors of the breast. Or, once more,
the characters of readiness to ulcerate may be imitated by innocent
tumors after injuries, or in exposure to continued irritation ; for thej
resist these things with less force than the similar natural parts do.
Hence, sloughing and ulcerating fibrous, erectile, and other tomon
have been often thought cancerous, and so described.
The respective tendencies to ulcerate can, therefore, be counted onlj
as constituting differences of degree between the innocent and the malig-
nant tumors. We may speak of a liability in the one case, of a pron^
ness in the other.
4th. The softening that often precedes the ulceration of malignant
growths can hardly be considered separately from the minute account of
their structure. I therefore pass it by, and proceed to their fourth dis-
tinctive character, which is to be noticed in the modes of their ulcera-
tion.
This is, that the ulcer which forms in, or succeeds, a malignant growth,
has no apparent disposition to heal ; but a morbid substance, like that
of which the original growth was composed, forms the walls or boundariea
of the ulcer ; and as this substance passes through the same process of
ulceration which the primary growth passes through, so the malignant
ulcer spreads and makes its way through tissues of all kinds.
In contrast with this character of malignant growths, it is observable
that beneath and around an ordinary ulcer of the natural tissues, or of
an innocent tumor, we find the proper tissues unchanged ; or, perhap8|
infiltrated and succulent with recent lymph, or the materials for repair;
or somewhat indurated with lymph already organized. The base and
margins of a cancerous ulcer are themselves also cancerous ; those of a
common ulcer are infiltrated with only reparative or inflammatory mate-
rial. In like manner, if ulceration extend through an innocent growth,
it may destroy it all, and no similar growth will form in the adjacent
parts, replacing that which has been destroyed : but in the ulceration of
cancer, while the cancerous matter is being constantly discharged, by
sloughing or ulceration, from the surface, new matter of the same kind,
AND MALIGNANT TUMORS. 827
knd in more abundance, is being formed at some distance from the sur-
Ace; 80 that, in a section through an ulcerated cancer, one does not
imve at healthy tissues till after passing through a stratum of cancer.
fith. Malignant tumors are, again, characterized by this: that they
not only enlarge, bat apparently multiply or propagate themselves ; so
that, after one has existed for some time, or has been extirpated, others
fike it grow, either in widening circles round its seat, or in parts more
remote.
Mere multiplicity is not a distinctive character of malignant diseases ;
far many innocent tumors may be found in the same person. But in
llie conditionB and circumstances of the multiplicity there are charac-
teristic differences. Thus, when many innocent tumors exist in the same
person, they are commonly, or always, all in one tissue. A man may
We a hundred fatty tumors, but they shall all be in his subcutaneous
&t: many fibrous tumors may exist in the same uterus, but it is so
nre, that we may call it chance, if one be found in any other part in
die same patient: so, many cartilaginous tumors may be in the bones
of the hands and feet, but to these, or to these and the adjacent bones,
dieyare limited.
There is no such limitation in the case of multiplicity of malignant
tnmors. They tend especially to affect the lymphatics connected with
the part in which they first arise; but they are not limited to these.
The breast, the lymphatics, the skin and muscles, the liver, the lungs,
may be all and at once, the seats of tumors. Indeed (and here is the chief
contrast), it is more common to find the many malignant tumors scat-
tered tlurough several organs or tissues than to find them limited to one.
Moreover, if there be a multiplicity of innocent tumors, they have
generally a contemporary origin, and all seem to make (at least for a
dme) a commensurate progress. But the more ordinary course of malig-
nant tumors is, that one first appears, and then, after a clear interval
jf progress in it, others appear; and these are followed by others, which,
irifli an accelerating succession, spring up in distant parts.
6th. A sixth distinctive character of malignant tumors is that, in
their multiplication, as well as in their progress of ulceration, there is
leareely a tissue or an organ which they may not invade.
In regard to their multiplicity, I have just illustrated their contrast
in this point with the innocent tumors; and a similar contrast is as
)bviou8 in the characters of the ulcers. It is seldom that a common
deer extends, without sloughing, from the tissues it has first affected
into any other; rather, as a new tissue is approached, it is thickened and
ndnrated, as if to resist the progress of the ulcer. But before a cancer-
VOB ulcer the tissues in succession all give way, becoming first infiltrated,
lien, layer after layer degenerating and ulcerating away with the can-
serous matter.
One may see this very well in bones. Specimens are to be found in
learly all the Museums, of tibiae (for example) on the {lOnX. %wx^^<^^ ^1
328 DISTINCTIONS OF INNOCBNT
which new bono is formed, in a circumscribed round or oval layer, a line
or two in thickness. This bone, which is compact, hard, smooth, tod
closely united with the shaft beneath it, was formed under an old nicer
of the integuments of the shin. But, on the other side, specimeiiB ane
found, which show that when a cancerous ulcer reaches bone, at onoe
the bone clears away before it ; and a cavity with abrupt, jagged, eateih
out edges, tells the rapid work of destruction.* Neither are specimeoi
rare, showing the progressive destruction of more various tissues; sooh
as a cancer of the scalp making way by ulceration through the penen-
nium, skull, and dura mater, and then penetrating deeply into the bnin;f
or one in the integuments of the shin going right through the tibia, aad
deep into the muscles of the calf.^
I
Such are the general characters of malignant tumors. Those of :
innocent ones are their oppositcs or negatives. Thus : innocent tnmoci ^
have not a structure widely different from that of a natural tissue : thej i
do not appear as infiltrations displacing or overwhelming the original ■
tissues of their seat : they do not show a natural proneness to ulceration;
nor is the ulceration, which may happen in one through injury or diseai^
prone to extend into the adjacent parts ; they do not appear capable of
multiplying or propagating themselves in distant parts : they do not
grow at the same time in many different tissues.
Now, the distinctive value of each of these characteristics of malignant
disease may be appreciated : indeed, I have myself lowered it, by show-
ing that each of them may be absent in tumors having all the other
features of malignancy, and that certain of them may be obs^rad
occasionally in tumors that in other respects appear non-malignant
But objections against each character separated from the rest are o(
little weight against the total value of all these characters of malignancy,
or of a majority of them, concurrent in one case. Similar objection
might be made against even the classifications of natural history : anA
none but such as are disposed to cavil at all nosology, could fail, ift
watching a series of cases of tumors through many years, to observe
that the great majority of them could be classed according as, in their
course, they did or did not present the characters that I have enumA-.
rated. Some cases would be found in which one or two of the signs
might be wanting, or, if I may so speak, misplaced ; but) putting these
aside, as exceptions to be regulated by future inquiry; and looking
broadly at the whole subject, no one could doubt that this division of
tumors into innocent and malignant may be justly made, and that the
outward marks by which they are discriminated are expressions of reil
difference in their properties and import.
* In the College Museum, Nos. 3082-3-3 A; 3267-8, and many others, illustrate
points,
t Museum of St Bartholomew's, vi. 57.
} Museum of the College of Surgeons, 232.
AND MALIGNANT TUMORS. 829
In what these differences may consist I shall not discnss till I have
completed my account of each kind of tumor. For the present I will
say only, that I think maligtiant tumors are local manifestations of some
specific morbid states of the blood ; and that in them arc incorporated
peculiar morbid materials which accumulate in the blood, and which their
growth may tend to increase. All their distinctive characters are, I
thinky consistent with this view; and the absence of the same characters
in innocent tumors may lead us to believe that they are usually local
diseases, the result of some inexplicable error of nutrition in the part
that they affect, and only in the same measure dependent on the state of
the blood as are the natural tissues, which require, and may be favored
by, the presence of their appropriate materials of nutrition. Or, when,
as sometimes happens, an innocent tumor begins its growth during, or
soon after, some general disease, we may suppose that it owes its first
formation to an abnormal condition of the blood : but that, when the
Uood recovers its health, the tumor subsists or grows on the nourishment
Replied by the normal materials of the blood. Instances of tumors
thfls constitutional in their origin, but subsisting as local diseases, will be
mentioned in the general history of cancers.
It may be best to speculate no further, either on this point, or on the
origin or determining causes of tumors. I could speak certainly of very
little connected with these points, unless it were of the error or insuffi-
ciency of all the hypotheses concerning them that I have proposed
to myself, or have road in the works of others. Ono of these alone
leems to need disproof: namely, that tumors, whether innocent or
OftUgnant, are due to the organization of effused blood, or of some
inflammatory exudation, or of the material of repair. The great objec-
tions to this view are as follows: 1. It is an almost infinitely small pro-
portion of injuries that are followed by the growth of tumors. 2. In a
hrge majority of cases of tumor, no injury or previous local disease is
SBOgned, even by the patients, as the cause of the growth. In 200 cases,
taken indiscriminately from those I have lately recorded, no local cause
whatever could be assigned for the growth of 155 tumors, of which 64
were innocent and 91 malignant : of the remaining 45, referred by the
patients to previous injury or disease of the part, 15 were innocent and
SO malignant tumors. 3. Blood extravasatcd, and the products of the
ioflammatory and reparative processes, arc not indifferent materials, such
as would pursue this or that direction or development, according to
chance, or some imaginary influence exercised on them. They have a
proper tendency to assume the form of fibro-cellular, fibrous, or osseous
tissue. They do not become, when their history can be traced, either
fatty, or perfectly cartilaginous, or glandular tissue, such as we find in
tnmors. 4. No intermediate conditions have been yet found between
blood or lymph and a tumor. And, lastly, all the facts relating to
mjuries, as favoring or determining the growth of tumors, are explicable
880 DI8TIK0TI0N8 0¥ INSTOCIVT
on the supposition that tho injury impairs for a time the nntritioi r^
of a part, and diminishes its power of excluding abnormal methods rf r^.
nutrition. ^ V?"
Narrowing now the objects of consideration to the innocent tamoa y-
alone, I will speak very briefly of their classification. f-^
A first subdivision of them may be made, according to the wmd ^'
arrangement, into the cysts or cystic tumors, and the solid tniBoni ^r^
There are, indeed, not a few instances in which tho two divisions overlip p*"^
or are confused. Thus, on the one side, in cases to which I havealreadf '^t^
referred, a solid growth may spring from tho inner walls of a cyst, aii| ii^
enlarging more rapidly than the walls do, may fill the canty, and com )^^
in contact and unite with tho walls ; and thus may be traced a cotaiplcte ; —
series of gradations from the cystic to the solid tumor. On the ockr | -r.
hand, cysts may be formed within solid tumors, and increasing not hm
rapidly than the solid structure, may reduce it to scarcely more thaa i
congeries of cysts, or to one great cyst. Such changes are illostralel
sometimes in fibrous tumors of the uterus : and I think, also, in tkt
tumors which Sir Astley Cooper called ^' hydatid disease** of the testida
But though there are these instances of confusion, yet the divisioii ii
very convenient, and is probably deeply and well founded.
Next, among cysts, some are filled with a simple fluid, containing M
organized matter, and resembling one or other of the fluids of mmi
cavities. These may be called simple or barren, or in most instaiicei»
serous cysts.
Other cysts contain organized substances, and may be named, u •
group, proliferous ; and the several members of the group jpMj te
described, according to their contents, as glandular, cutaneous, sefct-
ceous, dental, and the like.
Of the solid innocent tumors, no method of arrangement at prw«t
appears reasonable but the old one, which is founded on their likeneai W
the natural tissues. On this ground they may be arranged in the foDot-
ing divisions, with names, as specific names, expressing their several ft-
semblances — viz., fatty, fibro-cellular, fibrous, fibroid, and fibnvnucleated,
cartilaginous, myeloid, osseous, glandular, and vascular or erectile. An4
again, under each of these may be arranged certain varieties, indnding
instJMices that, in some uniform manner, deviate, without quite departing.
from the usual characters ; as the fibro-cystic, fibro-calcarcous, and other
varieties of the fibrous tumors.
In each assumed kind or group of these solid tumors, moreover, we
must make a division, acording to their mo<les of growth, and of con-
nexion with the adjacent parts. Some among them are only interme-
diately connected with the adjacent parts; a layer of tissue at once
separates and combines them, and, by division of this layer, such a tumor
may be cleanly and alone removed from the surrounding parts ; it may
be enucleated or shelled out from them. Thus, with a common fatty
AND MALIGNANT TUMORS. 881
tnmor, or a fibrous tumor of the uterus, if we cut along one part of its
anr&ce, we may, with a blunt instrument, detach the whole mass, by
qdittbg the layer of fibro-cellular tissue which, like a capsule, incloses
and isolates it.
These are what we commonly accept as the proper or typical tumors,
these which are '* discontinuous hypertrophies."
Other growths resemble these in every character, except in that they
are connected with the adjacent parts by continuity of similar tissue, and
ihiis appear as growths, not in, but of, the parts. Thus we cannot ex-
aedy isolate a polypus of the nose or of the uterus : the overgrown part
eaimot be enucleated, because the proper tissue of the nasal mucous mem-
brane, or of the uterine wall, is continued into it ; the tissue of the growth
iihere not only uniform, but continuous, with that of the adjacent parts.
So, too, with epulis : the gum itself, or the periosteum of the jaw together
iriih the gum, seems, by its own excessive growth, to form the tumor ; and
ia other fibrous tumors on bones, the fibres of the periosteum appear to
be in the growth, and to form part of it.
Such growths as these might be named " continuous hypertrophies,"
or ^outgrowths ;" and I will, in general, observe this distinction wherever
tbe same tissue is, in different cases, found in both form's of growth ;
calfa'ng the discontinuous masses tumors, the continuous ones, outgrowths.
IhnSy answering to the common fatty tumor, we find the pendulous and
eontinnous fatty outgrowths of the neck or the abdominal walls ; an-
awering to the fibro-cellular tumor that grows, as a discontinuous mass
in the scrotum or beneath the labia, we have the cutaneous outgrowths
or enlargements of these parts ; to the fibrous tumors of the uterus
answer the fibrous polypi or continuous outgrowths of its substance. All
these instances of clear distinction might lead us to think that a strong
definition line might be drawn to divide the whole class of innocent over-
growths into tumors and outgrowths. But when we como to the tumors
of bone and periosteum, and to the erectile tumors, we find the distinc-
tions vanishing, and in many instances no longer possible.
It may seem as if these "outgrowths" needed distinction from the
''infiltrations" which were spoken of as peculiar to malignant diseases.
rhe distinctions between them are well marked. In the outgrowth the
aew material is like that with which it is connected, or like its normal
rudiment, so that it is as if the tissue were itself outgrown ; but, in the
infiltration, the new material is dissimilar from that in the interstices of
irhich it is placed. And in the outgrowth the materials of the original
part appear to be at least maintained, if they are not increased ; but in
the •infiltration they degenerate and waste. We may compare, for this
contrast, the cancerous diseases of the skin, with the cutaneous out-
growths of the labia, nymphce, prepuce, or scrotum.
In thus briefly indicating that which appears still the most reasonable
832 DISTINCTIONS OF INNOCENT AND MALIONAHT TCXOBfc
method of classifying tumors, I have referred to difficulties which haiv
appeared to be insuperable objections to any attempt at an arrangeoMil
of these diseases. I will therefore state, so far as I can, what is the nrf
weight of these objections.*
First, it is said, such classifications cannot be well made, because, be
twecn each two assumed kinds or groups of tumors, intermediate examphi
may be found transitional, as it were, from one species to the other: tk
one, it is said, ''runs into" the other; or, as Mr. Abemethj expreurf 1^
it, *' diseases resemble colors in this respect — ^that a few of the primaij f
ones only can be discriminated and expressed, whilst the intermcdiali '^
shades, though distinguishable by close attention and comparatire ok ^^
servation, do not admit of description and denomination."t !^
This is exactly true ; but Mr. Abemethy seems to have felt that )m
sentence supplied the answer to the objection against classification hj
structure, which it expressed ; for, as he did not, because of the iiilce
mediate tints, refuse to name and arrange the primary colors, so neitkr
did he, nor need we, hesitate to name and classify diseases, and aiWNf
them the principal forms of tumors.
Moreover, the objection that structures may be found intermediate be
tween those belonging to the chief forms of tumors, may be as well nadi
against the use of names and systems for the natural tissues. There m
no strongly outlined characters defining any of the natural tissues tkt
arc ever imitated in tumors ; intermediate and confusing forms are foood
everywhere. The various forms of fibro-cartilage, for instance, fill ip
every possible gradation from cartilage to fibrous tissue : between fibre
celhilar and fibrous tissues, between ten<lon9, aponeuroses, and fsKis, ]
between epithelium and simple membrane, there are, in the natural titfueft.
the narrowest gradations. Yet we name and arrange the natural titfON
with some truth and much utility ; and so we may the tumors that re*
semble them.
Another objection against this classification of tumors is made on the
ground that there are some in which two or more different tissues are
mingled. Thus, tumors may be often found, in which fat and fibro-cvl-
lular tissue, or fibrous tissue and organic muscle, or cartilage and glan-
dular tissue, or other combinations, meet together. But, among theK«
some are imitations of natural combinations of tissues, as the fibrous tad
organic muscular tissues of the uterus are imitated by the so-calkd
fibrous tumors in its walls ; and of the others, it need only be remem-
bered that such combinations do occur, and these may be put aside from
any interference with arrangement, by making a series of mixed tumon,
or by adding to the description of each species the combinations into
which it may enter.
• The lK»«.t statement of thi»9o objfrtionii i« by Vogel ; but he has well answered his owa
aryuineiits by cii«reK<^rfiinK thoiii in his nomcnohitiin* of tiiinorH.
t An attem|H to form a ClaMiAcation of Tumors acfronling to their Anatomical Stniciuft.
Surgical Works, vol. ii. ed. IS 15.
8XXPL1 0T8T8. 888
Tet another objection is made, that the characters of tamers are not
constant, and that many mnst be reckoned as examples of one species,
which are not much, if at all, like one another.
This diversity of characters is, indeed, the great diflSculty with which
the pathology of tomors has to contend ; but the diversity is not to be
oiled inconstancy: it is due to the fact that each tumor has, like each
Bitond tissue, its phases of development, of degeneration, and of dis-
eue. Now we have scarcely yet begun the study of the variations to
which, in each of these phases, the several tumors are liable. We may
hare learned, for example, the general characters of cartilaginous tumors,
IS they grow in the most favorable conditions; but how little do wo know
of the various aspects these may present when they fail of due develop-
ment, or fall into various diseases, or variously degenerate ! Yet all these
changes have to be studied in the history of every tumor ; and it would
be IS reasonable to charge any natural tissue with inconstancy, because
h 18 altered in development and disease, as to hold that the similar
dirersity of tumors is an objection to their classification according to their
stmetore.
However, while I put this aside as an objection against classification,
let me not be thought to underrate it as a great difficulty ; it is the great
diflbulty with which we have to contend. The work we have to do is not
only to distinguish each kind of tumor from all other kinds, but, and in
order to this end, to distinguish, as I may say, each kind from itself, by
letming in each all the changes occurring in the various stages of its
life. The difficulty of such a task cannot be exaggerated, while we con-
sider the rarity of the objects to be studied ; but it must be overcome
before we can cease to speak of ^'anomalous tumors,*' and of '^strange
distempered masses," or, which is more important, before we can, even
after the removal of a tumor, speak with certainty of the issue of a case.
LECTURE XXII.
SIMPLE OR BARREN OTSTS.
The Oyits, or Oystic Tumors^ to which I shall devote this lecture and
the next, form a very numerous group, and have only or barely these
characters in common ; namely, that each of them is essentially a cyst,
sac, or bag, filled with some substance which may be regarded as entirely,
or for the most part, its product, whether as a secretion, or as an endo-
genous growth.
We may conveniently arrange cysts under the titles ^^ simple'* or
884 SIMPLB OB BARREH CTBT8.
(C
barren," and "compound" or '^proliferous;*' the former contiiniog
fluid or unorganized matter, the latter containing variously organiud
bodies.
Among the simple or barren cysts, we find some that contain a ftdd
like that of one of the serous membranes ; such are certain mammirj
cysts, and those of the choroid plexus: some are full of synovia-like fluid,
as the enlarged bursas : others are full of blood, or of colloid, or some
peculiar abnormal, fluid: while others, forming the transition betweei
the barren and the proliferous cysts, contain more highly organic secre-
tions, such as milk, or mucus, or salivary or seminal fluid. These seTenl
forms we may arrange with names appropriate to their contents; u
serous, synovial, mucous, sanguineous, colloid, salivary, seminal, ud
others.
Among the cysts, whether barren or proliferous, it is probable Alt
at least three modes of origin may obtain. Ist. Some are formed by
the enlargement and fusion of the spaces or areolae in fibro-celliilar,
areolar, or other tissues. In these spaces fluids collect and accmnnltte;
the tissue becomes rarified ; and, gradually, the boundaries of the spsen
are levelled down and walled in, till a perfect sac or cyst is formed, the
walls of which continue to secrete. Thus arc produced the bursae OTer
the patella, and others ; and to this we may refer, at least in some caMB^
the formation of cysts in tumors, and, perhaps, in other parts.
2dly. Some cysts are formed by dilatation and growth of natunl
ducts or sacculi ; as are those sebaceous or epidermal cysts which, formed
by enlarged hair-follicles, have permanent openings. Such, also, are
certain cysts containing milk, that are formed of enlarged portions of
lactiferous tubes : such the ovarian cysts formed by distended and over-
grown Graafian vesicles ; and such appear to be certain cysts formed of
dilated portions of bloodvessels shut off from the main streams.
3dly. Many, and perhaps the great majority of cysts, such as those
of the kidney, the choroid plexuses, the chorion, and the thyroid gland,
are formed by the enormous growth of new-formed elementary structures
having the characters of cells or nuclei, which pursue a morbid course
from their origin, or from a very early period of their development.
It might, on some grounds, bo desirable to classify the cysts according
to their respective modes of formation ; separating the "secondary cysts,"
as those have been called which are derived by growth or expansion
of normal parts, from the "primary," or, as they might be called, the
"autogenous" cysts. But, at present, I believe, such a division cannot
be made ; for of some cysts it is impossible to say in which method they
originate, and, in some instances, either method may lead to an apparently
similar result. Thus, some sebaceous or epidermal cysts are clearly formed
of overgrown hair-follicles; others are of distinct autogenous origin.
Some ranulae are probably formed by dilatation of the submaxillary duct,
obstructed by calculi or otherwise; others by anormal development of
6EKEBAL HI8T0BT OF CYSTS. 8S5
£itixict cjBtBf or possibly of a bursa between the muscles of the tongue.*
Some cysts in the mammary gland are certainly dilated portions of
dacts; others are, from their origin, anormal transformations of the ele-
mentary structures of the gland. But in each of these cases it may be
impossible^ when the cyst is fully formed, to decide what was its mode
of origin : whether by growth of parts once normally formed, or by
transformation of elementary and rudimental structures.
Of the three modes of the formation of cysts to which I have referred,
the first two, namely, that which is accomplished by expansion of areolar
iptces, and that by dilatation and growth of ducts or vesicles, scarcely
need an explanation.
Indeed, if it were not for some convenience in surgical practice, we
dumld not retain most of the cysts thus formed in the list of tumors ;
for their growth appears, in most instances, to be due only to the accumu-
litioQ of the contents of the obstructed tube or sacculus, and to be exactly
adjusted to this accumulation, and commensurate with it. Thus it is in
the cases of ranula with obstruction of the submaxillary duct, and the
Bmilar dilatations of the pancreatic duct ; in the cystiform dilatation of
the obstructed Fallopian tube ; in the dilated hair-follicles ; in bursas ;
ind in some others. These are all conventionally reckoned among cysts,
ind arranged with tumors : but several of the like kind are never so
reckoned : such as the cyst-like gall-bladder, dilated with thin mucus,
when the cystic duct is completely obstructed; the dilatation of the
ntems, filled with serum after closure of its external orifice ; the distended
sheath of a tendon ; and others. Convenience and common usage have
decided what cysts may be grouped with those which alone, we may anti-
cipate, will be classed with tumors when pathology becomes more accu-
rate and strict. Convenience alone, also, decides for the omission, from
so vague a class as this, of the sacs or capsules that are formed round
foreign bodies and solid tumors, and of the sacs that may be formed on
the free surfaces of extravasated blood or inflammatory exudation.
For the third method of formation enumerated above, a more detailed
account is required ; and this I will now endeavor to give.
The general structures of the cysts thus formed may be best studied
in those that are so commonly found in the kidneys, or the mammary or
thyroid gland, or in any instance of an ordinary serous cyst. Such a
cyst, when large enough for naked-eye examination, is usually constructed
of fine, well-formed, fibro-cellular tissue, of which the filaments are
commonly mingled with nuclei, or nucleus-fibres, and are variously inter-
woven in a single layer, or in many that are separable. The membran-
ous walls thus formed, are, in general, rather firmly connected with the
adjacent parts, so that the cyst cannot easily be removed entire ; and from
• See Fleiwhinan, in Schmidt's Jalirbticlier, 1811, B. 32, and Frerich?, Ucbcr-Gallert-
oder ColloidgeKhwOUte, Gottingen, 1847, p. 37.
889 6KNBRAL HI8T0BT Of 0T8T8.
these parts they derive the bloodvessels that usually ramify copiawl
upon them. They are usually, also, lined with epitheliom, which is gii|
rally of the tessellated form, and may consist, according to BokiteM^
of either nuclei or nucleated cells.*
I am not aware that minute examinations have been made of $^
modes of earliest formation of any of the cysts of this kind, that qj
common subjects of surgical consideration; but there can be iltfj
doubt that, in their formation, they resemble the cysts of the kidi^
and other internal organs. In these organs the origin and progrefl i
cysts have been profoundly studied by Rokitansky ;t and I shall U
describe them by giving an abstract of some of hb obsenratioitf^ t
illustration of a copy of one of his outline sketches of the niarii
structure of the cystic disease of the kidney. (Fig. 44.) They eoalil
and greatly extend the results obtained by the similar investigatioBS 4
Frerichs,! and they fully establish the accuracy of the obser^-atioM ij
the cystic degeneration of the kidney, which were made by Mr. ShM^|
to whom pathology is indebted for the first sure step in this rich patk4
inquiry. They may be repeated in almost any portion of a granrii
kidney containing cysts, or in a choroid plexus with cysts ; but^ I beiii«%
the process may be best traced in the cystic disease of the embmril
chorion — the hydatid mole, as it has been called.|| To this I shall agih
refer in the next lecture.
In a portion of a granular and cystic kidney, nests, as Rokitaa^f
calls them, of delicate vesicles, from a size just visible to that of a mSh^
seed, may be seen imbedded in a reddish-gray or whitish substaaOL
These differ in size alone from the larger cysts to which one's attcnMi
would be sooner attracted ; and on the other side, it is only in size tkC
they differ from many much smaller. For if a portion of such a nest h
examined with a microscope, one finds, together with the debris of tk
kidney, variously diseased it may be, a vast number of vesicles or cjrii
that were invisible to the naked eye.
The most striking of these have a wall consisting of layers of film
scattered over with curved nuclei (a), and are filled with granulated nniM
or, more rarely, with round or polyhedral cells, some of which ws]
contain a molecular or granular pigmental matter, (d.) In many d
these cysts, the nuclei or cells are reduced to an epithelial lining of tk
• Rokitansky says (Ueber die Cyste, p. 4) there is often no epithelium in the lii^
cysts, and their ^ inner layer is a nucleate<l, structureless, or striated biaitema, eitemily
splitting into fibres in tlie direction of the long axis of the oval nuclei it contain*." 1^
thelial celN, apparently altered so as to resemble very large cells of inflammatory lympb,0<
commonly foun<l in the tenacious contents of burs:e. M. GiraUles tclU ine that the cf^
which so often occur in the antrum arc cx)mmonIy lined with ciliary epithelium.
t Ueber die Cyste. Wien, IS.V).
X Ueber (rallort-oder Cf>lloidges<>hwQlste.
$ On Subacute Inllanimation of the Kidney, in the Medico-Chirurgical Transaciioni^ ^
xxz.
I Mettcnheimer, in Mailer's Archiv, 1850.
OINBBAL BtBTOKT OF CTSTB.
387
(jjit; and in Bome eT«n tfaia is absent, and the "buren" t^t ia fiUed
inA a cle«r or opaline adheuve flnid.
From the liie jnst Tisible to the naked eye, Buch eysta rory to
ii( of an inch in di-
uneter; and, together ^
vith theae, are ejwts
wboee walls (though
tlieir contents are like
tboH of the others)
CMuist of a stmctnre-
k« hyaline mem-
tmne: and these lie
is » stroma which is
eqully simple, bnt
Menu to develope it-
Klf gradually into a
Shrow stmctnre cir-
ntmsdibing the oysts.
Moreover, one finds,
in the same spedmens
(u in the lower part of
Fig. 44), stmctnres of the most varioua sizes, which, except in siie,
. agree completely with the last-mentioned simple and etmctnrelesB vesicles,
nd show every grade of size down to that which is just larger than a
nncIeDB. The smalleet of these contain a clear fluid, or are slightly
granulated: in the lai^er there is a central nucleus, and to fliis are
added a second, a third, and a fourth nucleus, and so on till there
appear several, which fill up the commensurately enlarged vesicle (c, e,
*, ka.) Now, in such a nucleus seem to lie the nucleus of the history of
development of those autogenous cysts, not in the kidney alone, but in
uiy part in which they may occur. A nucleus grows to be a cyst,
whether a simple or barren one, or one that has an endogenous pro<lno-
tion of nuclei or cells, or any other structures. And, perhaps, in the
same specimen, the early history of the nucleus iteolf may be traced;
for one sees (as in the same figure), together with the nuclei, still smaller
eorpnscles of all sices, down to that of the elementary granule so-called ;
and these, the larger they grow, the more are they like nuclei ; so that,
perhaps, the progress of the disease is from these granules, enlarging to
llie formation of nuclei, and thence pursuing some abnormal course.
It woald be tedious now to trace, from this general sketch of their
origin, all the phases through which such cysts may pass. Rokitansky
has done it amply. We have here the elementary constituents. But
the simple cyst-wall is capable, not only of growing, but of acquiring,
by appropriation and development of surrounding blastema, tho laminar
and nucleated fibrous tissue which we find in its full estate; acquiring
888 GJBNBBAL HIBTOBT OV 0TBT8.
these we may presume, just as more normally, the simple memlNrMiM
wall of a new bloodvessel acquires, as it grows, the nuclei and fibrm
tissue that belongs to its more perfect state. Such might be the leut
abnormal course of any cyst : but from this it may deviate ; thickeningp
acquiring continually new layers, calcifying, and in other ways showing
the signs of degeneration or disease. The contents, also, of the cyst
may assume even yet more various forms : to name only the eztremeB—
they may retain the simple state of liquid ; or with liquid there may be
a simple, or a specially secreting, epithelial layer ; or, a series of 8110-
cessively enclosed nuclei or cells may be formed within that which fini
enlarges ; or, the contents may acquire the structure of well-organiied
glands, or of cancer, or some other tissue ; and between these extremes,
according to conditions which we have no power to trace or explain, thej
may pass in any of the manifold ways of wrong, the ends of which I shaD
have to describe.
Important as the history of cysts may be in its direct bearings, yit
these are not all that we may observe in it. In their history I caimoi
but think we may discern an image of the first form and early progrM
of many innocent solid tumors also. For, as the cyst is tnu^ froB
the mere nucleus, or even from the granule, onwards to its extreme m
or complexity of structure or contents, so, it is very probable, from tbft
numerous correspondences between them, that these solid tumors abo
have a similar beginning in some detached element, or tissue-germ, or h
some group of such germs, which in their development and growth, may
coalesce, and then may appropriate, or exclude for absorption, the inte^
vening substance.
Thus, in the form of erring nuclei, we may, I think, almost apprehend
the structural origin of these cysts and tumors : yet, if we may, the
question still remains whether the elementary structures in which thej
begin be some new and special morbid elements, or some natural mdi-
mental structure perverted from their normal course. Mr. Simon, speak-
ing of the cysts of the kidney, regards them as " vesicular transforma-
tions of the ultimate structure of the gland ;'* and to this view, without
adopting some ingenious suppositions which he has connected with it, I
would adhere. For, unless a cyst or a solid tumor (assuming this modA
of their origin to be correct) were really a transformation of the nudeuSi
or a cell, in the part in which it grows, we could not understand the veiy
general similarity that we find between the contents of certain cysts and
the secretions or structures of the glands in or near which they occnr;
nor yet the likeness which commonly exists betwen the solid tumor and
the tissue in which it is imbedded. These things are as if the first begin-
ning of the abnormal growth were in some detached element of the
natural tissue, which element, being perverted from its normal course,
thenceforward multiplies and grows, conforming with the type in minute
GA8K0UB AND 8BB0UB CYSTS. 889
Mnokure snd oomposition, but more and more widely deyiating from it
m duqM and siie.
Such are the facts, and such the speculations that we may entertain,
nspeeting the origin, or, at least, the smallest visible beginning, of a
eyrt or an innocent solid tumor. Need I add that if even this be true,
we are yet far from the explanation of the cardinal point in the pathology
of tamors — ^their continual growing. Why should these detached tissue-
germs, or any less minute and less isolated portion of an organ, grow
vlule all other germs and parts that are most like them remain un-
dianged ? I have already confessed my ignorance.
I will endeavor now to illustrate the histories of particular forms of the
Bim|de or barren cysts.
1. The first that may be enumerated are Gaseous Gtsts. I know
indeed, concerning them only the specimens placed by Hunter in his
mnsenm;* but these should be admired, or almost venerated; for their
Ustories include the honorable names of Hunter, of Jenner, and of Caven-
dish. Ifr. Hunter says of them, — ^'I have a piece of the intestine of a
log, which has a number of air-bladders in it." ... ^'It was sent to
Be by my friend Mr. Jenner, surgeon, at Berkley, who informed me
tint this appearance is found very frequently upon the intestines of hogs
that are killed in the summer months." ''Mr. Cavendish was so
kind as to examine a little of this air; and he found 'it contained a
little fixed air, and the remainder not at all inflammable, and almost com-
pletely phlogisticated.' "f
What a relic have we here ! Surely, never, on an object so mean to
C(Mnmon apprehensions, did such rays of intellectual light converge, as
on these to which were addressed the frequent and inquiring obser-
vation of Jenner, the keen analysis by Cavendish, and the vast com-
jwehension and deep reflection of John Hunter ! Surely, never were the
dements of an inductive process combined in such perfection ! Jenner to
observe; Cavendish to analyze; Hunter to compare and to reflect.
2. The Sebous Ctsts, or Hygromata, are, of all the order, the most
abundant. The term includes nearly all such as have thinly liquid, or
honey-like contents, of yellow, brown, or other tint. Their most fre-
quent seats are, by a hundred-fold majority, in or near the secreting
glands or membranes, or the so-called vascular glands ; but there is
scarcely a part in which they may not be found. Their frequency in con-
nexion with secreting structures has led some to hold that they are all
examples of perverted epithelial or gland-cells; but their occurrence in
such parts as bones and nerves, among deep-seated muscles, and in
fibrous tumors, makes it sure that they may originate independently of
* MuseniT) of the Coll. of Surg., No. 153-4.
f See Hunter's Works, vol. iv. p. 98, and Description of PI. xxxvii.
S40 SEROUS OTSTS.
gland-cells ;* though why any clement of a solid tissae should retiin du
vesicular form which it has in its germ-state, and in that form grow, m
cannot tell.
Of this numerous group of serous cysts, however, I will speak at pre-
sent of only such as may best illustrate their general pathology, tod
are of most importance in surgical practice ; and I will, to these ends,
refer chiefly to the cysts in the neck, the mammary gland, and the gmni.
Single serous cysts in the neck form what have been called ''hydrocele!
of the neck,'* and are well exemplified by a specimen in the Museum of
the Collegc.f This is a single oval cyst, with thin, flaccid, membranov
walls, which even now, after shrinking, measures more than six inches
in its chief diameter. It was successfully removed by Mr. Thomas
Blizard from between the platysma and sterno-mastoid muscles; and a
part of it is said to have passed behind the clavicle. It was filled with
a clear brownish fluid.
Such cysts, but various in size and other characters, are more apt to
occur in the nock than in any other part of the body. Many are single
cysts like this ; but others are complex, having many cavities, whether
separate or communicating; and some consist of very numerous cysts,
even of hundreds, clustered in one comparatively firm mass*
In situation, too, they are various. In some cases they lie in the
front of the neck; in others, at one or both sides : they may lie by the
lower jaw, over the parotid, by the clavicle, or anywhere and everywhere
in the mid-spaces. And in any of these situations they may extend
very deeply among the structures of the neck, and may adhere to them
so closely, and may so thinly cover them, as scarcely to conceal them
when laid open. Their date of origin is often obscure. In many, per-
haps in the majority of cases, they appear to be congenital ; but they may
be first observed at any later period of life. Last year Mr. Lawrence
removed a collection of four large cysts from over the parotid gland and
mastoid region of a man, twenty-eight years old, who had observed their
beginning only seven years previously. Three of these were filled with
serum, and one with pus.
Of course, in such a variety of forms, there must be more than one
* Some very interesting specimens of serous cysts in bones are in the Museum of St.
George's Hospital. They are described by Mr. Ctpsar Hawkins, in his Lectures on Tumors,
in the Medical Gazette, vols. xxi. xxii. ; and in the Clinical Lecture in the same, vol. zzv. pi
472. See also a remarkable case by Vanzetti, in Schuh (Pseudoplasmen, 175). Then an
some remarkable specimens of cysts in the antrum, in the Museum of St Thomas's Hospital,
prepared by Mr. Wm. Adams, who showed them to me. M. Giraldds considers all such
as these to be formed by cystic disease of the gland-structures discovered bj him in the
mucous membrane of the antrum.
t Mus. Coll. Surg. 146. Many well-marked examples of the disease in all its forms are
recorded by Dr. O'Beirne (Dublin Jour, of Med. and Chem. Sc. vol. vi. p. 834) j Mr. Lawrence
(Med.-Chir. Trans, vol. xxii. p. 44) ; Mr. Cspsar Hawkins (Med.-Qiir. Trans, vol. xxii. p. 231);
Mr. Liston (Practical Surgery, p. 330, ed. 1840); and others. A monograph by Wernlier
(Die angeborcnen Cysten-Hygrome, Gicssen, 1843) is referred to by Brucli, I. c, but I hare
not been able to see it.
-9
1
8KBOU8 0TBT8. 841
Idndy in the group of oystfi that are thus, for mere convenience, placed
together. The variety of origins, indeed, to which cysts in the neck may
be traced, gives them peculiar interest in relation to the general patho-
Io|gr of cystB.
Some are evidently connected with the thyroid gland ; though, being
on^y developed, and growing to a very large size, their relation to it
may be at length obscured, and they may appear, during life, quite iso-
kled. A woman, forty-eight years old, was under Mr. Vincent's care,
in St Barthdomew's Hospital, in July, 1841, with a tumor in the front
of her neck as large as the head of a child two years old. The tumor
nntiined fluid, which was twice withdrawn with a trocar. At the first
time die fluid looked like serum, but coagulated spontaneously ; at the
Moond, it waA mixed with blood. After the second operation the cyst
inStmed and discharged grumous and sanious pus ; but it also enlarged
I foiekly, and the patient died unexpectedly, and rather suddenly, suf-
focated.
The preparation* displays a cyst occupying nearly the whole right
lobe of the thyroid gland : its walls are nearly two lines in thickness ;
its cavity was full of lymph, pus, and blood : and the sudden death was
doe to a discharge of a great part of its contents into the pharynx and
laiynz, through an ulcerated aperture into the former.
Besidee these cysts which lie within the thyroid gland, some that lie
near to it are very probably of the same nature ; cysts formed in some
ondying portion of the gland, such as I referred to in the last lecture.
Bat of this mode of origin we can scarcely have a proof when the cyst
is fuHy formed and largely grown.
Other of these cysts in the neck appear to be transformations of vas-
cnlar tumors ; %, e. of erectile vascular growths or nsevi. I shall refer
to this point again : it is made probable by the close connexion which
some of these cysts have with large deep-seated veins; by the occasional
opening of bloodvessels into their cavities; and by their sometimes
distinctly forming portions of vascular nsevi. A girl, three and a half
years old, was under Mr. Lawrence's care, in 1849, in St. Bartholomew's
Hospital, with a large soft and obscurely fluctuating tumor covering the
greater part of the left side of the neck, and the lower part of the
cheek. Such a swelling had existed from birth, but it had of late en-
larged very much. It was composed of a cluster of close-set cysts,
containing spontaneously coagulable fluid ; but at its upper part a firmer
portion of its mass consisted of a collection of tortuous and dilated
bloodvessels, like those of a nsevus. The examination made of it, by
Mr. Coote,t after its removal, was such as to leave little doubt in his
mind that it had origin in or with a nsevous growth ; and other cases,
* Museum of St. Bartbolomew's Hospital, Ser. xxii. No. 10.
f Lectnre, by Mr. Lawrence, in the Medical Times, November 30, 1850.
84J2 SBBOTJS CT8TS.
to which I shall refer in speaking of erectile tumors, have confirmed thii
view, especially some of those which are published by Mr. Hawkins.
But when we have separated all the serous cysts in the neck that mtj
be referred to these two sources, there will probably still remain mny
that we can assign to no such mode of origin, and which at present m
must class among primary or autogenous cysts, independent of any secret*
ing structure.
Among these are some with fluid contents of peculiar viscidity, ropj,
or honey-like, and deriving a peculiar aspect from including abundant
crystals of cholestearine. Such contents may occur, perhaps, in any cjit
in the neck or elsewhere; but they appear to be comparatively frequent
at or near the front of the larynx. In the College Museum there ii
such a cyst,"^ attached to the hyoid bone of a sailor, who was between
fifty and sixty years old, and in whom it had existed nearly as longu
he could remember. It contained a brownish-yellow, grumous, honej-
like fluid, with abundant crystals of cholestearine.
In 1849, Mr. Layrrcnce had, at St. Bartholomew's Hospital, a patient,
thirty-five years old, on the left side of whose neck, directly over tnd
closely attached to the thyro-hyoid membrane, was a smooth oval tumor,
about an inch in length. He had observed a regular increase of diii
tumor for five or six years; but its bulk and deformity alone were ineoih
venient. Mr. Lawrence freely cut into it, and let out a thick honey-^
fluid, in which large groups of crystals of cholestearine were visible even
with the naked eye. The cyst, after the incision, suppurated, and then
the wound healed, and the patient left the hospital quite well : but I
have lately seen him with an appearance as if some remains of the cyst
were again filling.
Cysts like the last-described are not uncommon in or near the gums,
lying usually behind the reflection of the mucous membrane from die
gum to the cheek. Their occasional large size, ,and their thick tough
walls obscuring the sense of fluctuation, may make them at first look
formidable. A woman, thirty-eight years old, was under my care in
1849, in whom, at first sight, I could not but suppose something was dis-
tending the antrum, so closely was the deformity of the face due to such
diseases imitated. But the swelling was soft and elastic, and projected
the thin mucous membrane of the gum of the upper jaw, like a half-empty
sac. I cut into the sac, and let out nearly an ounce of turbid brownish
fiuid, sparkling with crystals of cholestearine. The posterior wall of the
cyst rested in a deep excavation on the surface of the alveolar border of
the upper jaw ; an adaptation of shape attained, I suppose, as the result
of the long-continued pressure of the cyst, which had existed six years.
* Mus. Coll. Surg. 148. These, I presume, are examples of Mcliceris. The cysts which
MOller describes under the name of cholesteatoma are quite different from these, and wiU
be noticed with the cutaneous cysts in the next lecture.
8KB0US CT8TS. 848
At nearly the Bftme time a young man was under my care with a simi-
lar BweUing of larger siie, which he ascribed to an injury of the gum
^ or alveolar border of the upper jaw only six months previously. In
neither of the cases could I find any disease of the maxillary bone ; but
it sometimes exists in intimate connexion with these cysts, and sometimes
the fiuig or socket of the nearest tooth appears diseased. I lately saw a
hdy in whom a small cyst of this kind had existed twenty-seven years,
ilmoBt daily discharging and refilling. It had its origin in a blow by
¥hich the two median upper incisors were loosened. One of them was
again firmly fixed ; the other had remained slightly loose, and its crown
laadark.
[ la no organ is the formation of cysts so important than in the mam-
[ mary gland. Every variety of them may be found here : but I will speak
i it present of only the serous cysts.
Some of these cysts are dilated ducts, or portions of ducts grown into
tiie cyst-form. During lactation, cysts thus derived may fill with milk,
and may attain an enormous size, so as to hold, for example, a pint or
more of milk.* In other cases they may contain the remains of milk, as
&tty matter, epithelial scales, kc. ; or they may be filled with transparent
ntery fluid, without coagulable matter ;t but much more commonly they
oo&tain serous fluid, pure, or variously tinged with blood or its altered
eoloring matter, or various green, or brown, or nearly black fluids.^
The complete proof of the origin of some of these cysts as dilated
portions of ducts is, that by pressure they may be emptied through the
nipple, or that bristles may be passed into them from the orifices of tubes.
But although these facts may be often observed, yet I agree with Mr.
Birkett in thinking that the majority of cysts in the mammary gland are
formed in the manner of the renal cysts, to which, indeed, they present
many points of resemblance.
The most notable instances of mammary cysts are those in which the
whole of the gland is found beset with them. This may occur while the
proper substance of the gland appears quite healthy ;§ but I think it
more commonly concurrent with a contracted and partially indurated
state of the gland ; a state which, independent of the cysts, appears
similar to cirrhosis of the liver, and has, I think, been named cirrhosis of
the mammary gland. Its coincidence with cysts proves its nearer rela-
* See a case by M. Jobert de Lamballe, in the Med. Times, Jan. 4, 11, 1845; and a col-
lectioo of cases by Mr. Birkett in one of which ten pints of milk were evacuated (Diseases
of the Breast, p. 201).
t Brodie, Lectures on Pathology and Surgery, p. 155.
f Their various contents are well shown in Cooper's Illustrations of Diseases of tlie Breast,
PL i.; and a full account of all the diseases of this class is given by Mr. Birkett in his work
already cited.
$ Two such cases are described by Sir R C. Brodie (Lectures on Pathology and Surgery,
p. 139).
844 SEROUS 0T8TS.
tlon to that shrivelled and contracted state of the granular kidney witk
which the renal cysts are so commonly connected ; or (when the cystl
are formed by partial dilatation of the ducts), to the shrivelled, indurated i
state of the lung that may coincide with dilatation of the bronchL
The cysts in these cases are usually of small size, thin-walled, full rf
yellow, brown, green, and variously deep-colored fluids; fluids that an
usually turbid, various in tinge and density, but not usually mudi denw
than serum. They do not lie in groups, but are scattered througb, it
may be, the whole extent of the gland ; and their walls, though thin, an
tough and tense, and very closely adherent to the surrounding gland*
substance. Similar small cysts are sometimes found in connexion witk
hard cancer of the breast ; and in this case they have been called by Mr.
Hunter and others '^ cancerous hydatids :" but their proper relation m
such cases appears to be, not with the cancer, but with the ooincidently
shrivelled gland.
In this disease of the mammary gland there is no reason to believe %
malignant nature, though the coincidence with cancer appears not ran^
yet the diagnosis between it and cancer is not always clear, and manj
breasts have been removed in this uncertainty. I once saw such a oaM^
and it ended fatally. A woman, fifty years old, had, in her left breai^
just below the surface of the mammary gland, a small, smooth, oval, and
movable tumor. It felt firm, but not hard ; but, external to it, in a lint
extending towards the axilla, were two or three small round ^^ knots,"
scarcely so large as peas, and quite hard. In the axilla was an enlarged
gland. The breast was soft, flaccid, and pendulous. The tumor was
sometimes painful, and a serous and bloody fluid often flowed from the
nipple. The patient's youngest child was sixteen years old, and the
tumor had been noticed six months, having arisen without evident cause.
There was doubt enough about the diagnosis of this case to suggest that
the tumor should first be cut into. An incision exposed the cavity of a
cyst full of dark, turbid, greenish fluid, and near it many more cysts.
Similar cysts pervaded the whole extent of the gland, and the whole
breast was therefore removed. Many of the cysts communicated with
lactiferous tubes, from which bristles could be passed through the nipple.*
In this case one comparatively large cyst existed, with many of much
smaller size. In more usual cases one cyst has a yet greater predomi-
nance over the others, or even exists alone. Sometimes, in such instances,
the removal or laying open one large cyst has been sufficient ; but in some,
smaller cysts neglected have enlarged, and the disease has appeared to
recur.f
The single cysts of the mammary gland may become enormous. I
• In the Museum of the Middlesex Hospital is a breast from a woman in which both
mammary glands were thus diseased. In the College Museum, Nos. 101 and 152 best
illustrate the disease.
t Sir B. C. Brodie, loo. cit. p. 14G, note.
STNOYIAL AND MUCOUS CT8TS. 846
Imow not what boundary may be set to their possible size ; but I find one
case in which nine pounds of limpid '^serosity*' were produced in three
months in the breast of a woman thirty years old.'*' In this case the
laQs of the cyst were thin, and the fluid serous ; and the fact illustrates
a general rule, that the cysts which contain the simplest fluids, and which
haTe the simplest walls, are apt to grow to the largest size : thickening
of eyst-wallB, and, much more, their calcification,t are here, as elsewhere,
Bgns of degeneracy, and loss of productive power.
It would appear as if any cyst of the mammary gland might, after
ume time of existence in the barren state, become prolific, and bear on
ill inner surface growths of glandular or other tissue. But of these pro-
liferous cysts I will speak in the next lecture.^
8, Of Synovial Cysts I need say very little. Under the name may
be included all the anormal bursas, or ganglions, as they are called. In
diese, again, two methods of formation probably obtain. Some, of which
the best example is the bursa over the patella and its ligament, are
merely enlargements, with various transformations, of burs» naturally
esBting. Not materially difierent from these are the bursas which form
anew in parts subjected to occasional localized pressure, and which ap-
pear to arise, essentially, from the widening of spaces in areolar or fibro-
eellnlar tissue, and the subsequent levelling or smoothing of the boundaries
of these spaces. But others, such as the bursse or ganglions which form
about the sheaths of the tendons at the wrist, appear to be the cystic
transformations of the cells inclosed in the fringe-like processes of the
synovial membrane of the sheaths. The opportunities of dissecting these
are rare ; but I believe there is a close resemblance, in mode of formation,
between them and the cysts of the choroid plexus. Rokitansky has
shown that these are due to cystic growth in the villi appended to the
margins of the plexus, which villi are very similar, in their constituent
Btmctnres, to the processes of the synovial fringes. And the probability
of similar origin is enhanced by the likeness of the contents of the cysts,
in both cases, to the fluids secreted by the fringes in the normal state.
4. Under the name of Mucous Cysts we may include all such as are
* Case by M. Marini, cited by M. B^rarii, " Diagnostic difTerentiel des Tunieurs da Sein,*'
p. 86.
t For a case in which the walls of a cyst in the breast were calcified , and crackled like
those of ossified arteries when pressed, see B^rard, loc. cit p. 56.
% Haying in view only the illustration of the more general pathology of these cysts, I have
not referred to more special instances of them. Examples enough are to be found in all the
works here quoted. Neitlier have I mentioned any analysis of the contents of serous cysts ;
for few have been made, and these few were made on such various materials, that no general
account of them can be rendered. Several are cited in Simon's Medical Chemistry ; and in
Frerichs, Ueber Gallert-oder ColloidgeschwQIste, p. 7-9, &c. ; and by Virchow, in the Ver-
handlungen der med.-phys. Gesellsch. in WQrzburg, B. ii. p. 281. See, also, on the contents
of ovarian cysts, Dr. Tilt's papers in the Lancet, June, 1850.
846 MUCOUS CT8TB.
formed in connexion with simple macous membranes, or with glandular
structures which we call mucous, while we know no other or pecnliir
office served by their secretions.
There may be many cysts of this kind ; but the best examples appev
to be those that may be named Nabothian and Cowperian cysts. Tiie
former probably originated in cystic degeneration of the glands of tk
mucous membrane about the cervix uteri. Protruding, either alone, or
with polypoid outgrowths of the mucous membrane, they are observed
successively enlarging, then bursting and discharging their mucous oob-
tents, and then replaced by others following the same morbid course. Or,
instead of clusters of such cysts, one alone of larger size and simpler
structure may be found.*
The Gowperian cysts appear to be connected with the Cowper's or
Duvernoy's glands in the female. Whether arising from dilatation of
the duct, or from cystic transformation of the elementary structures of
the gland, cannot be yet stated ; but, in the exact position of the Cow-
per's gland, and projecting into the vagina near its orifice, a cyst is ofiei
found, of regular oval shape, thin-walled, of uncertain size, but growing
sometimes to the capacity of a pint. Commonly the contents of such a
cyst are a colorless, pellucid, or opaline ropy fluid, like that found ia
the closed-up gall-bladder. But from this they often vary. I have seea
the contents of such cysts like the ink of the cuttle-fish, like the fluid of
melanotic tumors, and like thick turbid coffee ; or, to the sight, thej
may exactly resemble fluid fs&cal matter.f Moreover, these cysts are
very apt to inflame and suppurate. Many abscesses projecting into the
vagina have in these their origin ; and the treatment these abscesses re-
ceive, by free incision, is, I believe, appropriate for the cysts under all
conditions.
It is not apparent upon what the varieties in the contents of these cysta
depend. The only instances that I could minutely examine were the two
following : — In the first, a woman, 25 years old, under the care of Dr.
West, had a smooth oval swelling in the lowejr and fore part of the right
labium, projecting on its inner surface, and nearly an inch in diameter.
This had been observed slowly increasing for six years, and had commenc-
ed three months after parturition. It was not painful. I punctured it,
and let out about three drachms of pellucid fluid, like mucus, or the white
of egg. The cyst had a polished white internal surface, and the fluid
contained numerous corpuscles, like very large white blood-corpuscles,
and like such as are commonly found in the tenacious fluid of bursas. The
cyst closed on the healing of the wound : but two years afterwards either
it, or some other part of the gland similarly diseased, appeared again.
* A remarkable example of a cyst thus, I suppose, originating, is in the Museum of the
Middlesex Hospital.
t As in a case related by Mr. Ctesar Hawkins in his Lectures, Medical Gazette, vol. ■«»"^
and in two cases by Lebert, Abhandlungen, p. 109.
8AHeUIHE0nS OTSTS. 847
In the other oase, the patient was fortj-five years old, and under the
ve of Mr. Stanley. The tumor was nearly regularly oval, occupying
lie whole length of the right labium, and obstructing the vagina. She
lid oheeiTcd it increasing for four years : it was painless, but had been
An Btmek. A firee incision gave issue to about fourteen ounces of thick,
liadorcnM, dark brown fluid, like turbid coffee. The walls of the cyst
ive about one-third of a line thick, tough, compact, and closely connected
feiflk the surrounding tissues. Mr. Abemethy ICingdon, who examined
fta contents, found abundant molecular matter, and granule-masses, to-
ffAvv with groups of cells, apparently resembling epithelial cells of vari-
5. The Sanouineous Ctsts, or cysts containing blood, are, probably,
k many instances, very nearly related to the serous. Some may be ex-
|Uned by an accidental hemorrhage into the cavity of a serous cyst ;
m event corresponding with the transformation of a common hydrocele
falo an hematocele. The contents of some of these cysts are, indeed,
Jvt Eke those of an hematocele, with fluid and coagulated and variously
leooloriied blood.* But some cysts appear, from their origin, to contain
}koi ; and this blood, I think, always remains fluid till it is let out, while
iai which collects by hemorrhage into a serous cyst is generally partially
V wholly coagulated. Some of these cysts with blood are found in the
ttne positions and circumstances as the serous. Thus, in the neck, a
teries of cases of blood-cysts might be collected, exactly corresponding
Vith the serous cysts in that part, and, like them, probably derived from
various origins, some lying in the thyroid gland, some near it, some trace-
ible to connexion with vascular nsevi, some of proper origin.
Of the last class one appeared to be, which was in St. Bartholomew's Hos-
pital several years ago. A lad, about sixteen years old, was under Mr.
Stanley's care, with a large, oval, and somewhat pendulous swelling in
the left side of the neck, which had existed many years, and appeared
merely subcutaneous. It was punctured, and about sixteen ounces of
fluid blood escaped, which soon coagulated. After this the cyst closed ;
a result more favorable than may generally be anticipated from such
naple treatment : for usually these like other cysts, are not obliterated
uiless after free incision.
In the parotid gland, also, cysts containing fluid blood have peculiar
interest. In 1848, 1 assisted Mr. Stanley in the removal of one which
Isy quite within the parotid of a gentleman about forty years old. It
W been for some years increasing in size, and lay beneath some
Wches of the facial nerve, from which the need of separating it with-
* Such hemorrhages are frequent in cysts of the thyroid gland (Frerichs ; Rokitansky ;
Mnsniin of the College of Surgeons, 1502). Thus, also, we may explain the hematoceles of
^ipennitic cord, as io Mus. Coll. Surg. 2460 ; and Mus. St Bartholomew's, Ser. xxviii. 11.
848 SAKOriNEOUS ctsts.
out injnry made its removal very difficult. This, however, was safelj
accomplii^hed, and the patient remains well.
At nearly the same time, a man, 25 years old, was under my care witk
a similar cyst, which had been increasing without pain for two yem
It lay in the parotid, but very near its surface. I punctured it, aad
evacuated two or three drachms of bloody-looking fluid, with soiBe
grumous and flocculent paler substance intermingled. This fluid coagt*
lated like blood, and contained blood-cells, much free granular matter,
crystals of cholestearine, and what appeared to be white corpuscles of
blood acquiring the character of granule-cells. The cyst filled agiii
with similar fluid after being thus evacuated : I therefore dissected it
from the parotid gland, and the patient recovered.
Occasionally, one meets with sanguineous cysts, which derive a peculiir
aspect from a columnar or fasciculated structure of their interior, making
them look like the right auricle of a heart. This was singularly the caae
in one which I assisted Mr. Macilwain in removing from over the lower
angle of the scapula of a lad 15 years old. It had existed more tbin
eight years, and grew rapidly, while in the last year, he was actively it
work. It was now also painful. It felt like a fatty tumor, but proved to
be a cyst thus fasciculated like an auricle, with a finely polished internal
surface, and containing about an ounce and a half of liquid blood. Its
walls were from one to two lines in thickness, and seemed in great put
made up of small cells, such as one sees in a bronchocele, full of seroos
and bloody fluids. No trouble followed the operation, and the patient
remains well twelve years after it.*
A cyst presenting the same peculiarity of internal surface was re-
moved by Mr. Stanley, in October, 1848, from over the pubes of a boy
13 years old. It was observed increasing for nine months, and part of
it, consisting of a simple thin-walled serous cyst, was transparent ; but
behind, and projecting into this, was a more thickly walled cyst^ con-
taining about a drachm of dark liquid blood, and on its surface Sua-
culate and polished like an auricle. Its walls were well defined, formed
of fibro-cellular tissue imperfectly filamentous and nucleated, and I could
find no epithelium lining it. The operation was successful.
It is not improbable, I think, that both these cases may have had
their origin in vascular nasvi, like other cysts containing blood, to which I
shall refer in speaking of erectile tumors. I will now only refer to cer-
tain cysts which, without any erectile formation, appear to be derived
from portions of veins dilated, and obstructed, and shut-off from the
stream of blood. Such an one was removed by Mr. Lloyd, many years
ago, from a man's thigh. It lay in the course of the saphena vein ; but
neither that, nor any other considerable vein, was divided in the opera-
tion, or could be traced into the cyst. This cystf was of spherical
• Tlie cyst is in the Museum of St. Bartholomew's, Ser. zxxv. 38.
t Museum of St. Bartholomew's Hospital, Appendix, 10.
0IL-CT8T8 AND COLLOID CTSTS. 849
M>at an inch and a half in diameter, closed on all sides : its
nre tough, and polished on their inner surface ; it was full of dark
K>d, and its venous character was manifested by two valves, like
F veins, placed on its inner surface. On one of these a soft
1188, like an intra-cystic growth, is seated.*
nrrs containing oil or fatty matter, without any more highly
Bd substance, are very rare. Many contain fatty matters mingled
rous, epithelial, and other substances ; but in these the fatty con-
is probably the result of the degeneration of the other contents,
lowever, appear to contain fatty matter alone. Mr. Hunter pre-
& specimenf of what he marked as '^ oil from an adipose encysted
' It was taken, I believe, from a cyst that grew ^^ between the
bit and the upper eylid" of a young gentleman. When recent,
lescribed as " pure oil, perfectly clear and sweet, which burnt
rerj clear light, and did not mix with aqueous fluids, and when
I to cold, became b8 solid as the human fat."
)60, Mr. Wormald removed a small cyst from a woman's breast,
bents of which appeared to be pure oily matter, that congealed
nbstance like lard, and contained crystals of margarine, but no
ed corpuscles. The patient remains well. Schuh^ relates two
' cysts under the brow, which contained similar oily matter, and
rails had all the structures of skin, with implanted hairs.
)Lli0XD Cysts are, at present, a very ill-defined group ; the term
1" being used by Frerich8,§ and other recent German writers,
liose morbid materials that are pellucid, jelly-like, flickering, half-
' more or less closely resembling the material found in gelatini-
[veolar, or colloid cancer. Such a material is common in the cysts
shoceles, and in those of the kidney ; especially, I think, in those
ure not associated with contraction of the renal substance, and
hullie, and other writers of his time, described as hydatid disease
kidney,
contents of these cysts may present the most diverse conditions ;
I of all densities, from that of dilute serum to that of a firm
oay range between pellucidity and the thickest turbidness ; may
II hues of yellow, olive-green, orange, brown, pink, and nearly
The thick and pellucid contents of such renal cysts are enume-
I examples of colloid matter ; so are the contents of ranulas, and
J bursse ; but the type is the material of the so-called colloid
B Museum of King's College is a large cyst removed from a thigh, into which it is
aphena vein opened.
Coll. Surg^ 181 : Pathological Catalogue, vol. iv. p. 177.
r . . . Pseudoplasmen, p. 144.
r Gallert- oder CoUoidgeschwQlste.
850 SBMIKAL 0TST8.
cancer. This, however, is beyond my present range ; and I pass by ]t|
referring only to the already cited works of Frerichs and Rddtanskj,
and to that of Bruch,'*' for the best information yet supplied.
8. The last group of cysts of which I shall now speak includes midi
as contain secreted fluids, like those of the glands, by the dilated dudi
or transformed elements of which they are formed. Such are the cyiti
in the breast that contain milk, and probably many instances of ranuli.
The origin of the former is, probably, in dilatation of lactiferov
ducts : that of the latter is uncertain. But the examples of this gronpi
of which I wish more particularly to speak, are the Seminal Cy8T8|
including under this name those that are usually called encysted hydro-
celes, or hydroceles of the spermatic cord. Their various forms ire
fully described by Mr. Ourling,t and are well illustrated by specimenB
in the Museum of the Gollege.| They are usually thin-walled spherical or
oval cysts, imbedded in, and loosely connected with, the tisane of the
cord. They may occur singly, or in a group. Their most frequent sett
is just above the epididymis, but they may be found in any part of tlie
spermatic cord. Their walls are formed of fibro-cellular tissue, and they
may be lined with delicate tessellated epithelium. Their contents are
usually a colorless, slightly opaline fluid, like water, with which a littk
milk has been mingled.
The discovery was made at the same time, and independently, by Ifr.
Lloyd and Mr. Listen, § that the fluid obtained from these cysts usuallj
contains the seminal filaments or spermatozoa. Repeated observatiou
have confirmed their discovery ; and both the existence of these bodiea^
and the usual characters of the fluid, justify the speaking of it as a
diluted or imperfect seminal fluid, and, therefore, of the cysts, as '^se-
minal cysts."
It was my lot, I believe, first to dissect some of these cysts ;l| and I
found that they had no open communication or other connexion with any
part of the secretory apparatus of the testicle, and that their relation to
the epididymis, on which they lay, was such as to forbid the suppositioB
of the seminal secretion being transmitted to them from the tubes. I
suggested, therefore, that these cysts were formed quite independently
of the tubes ; and that being seated near the organ that naturally secretes
the semen, they possessed a power of secreting a similar fluid ; just as
cysts beneath the hairy parts of the body may produce hair and epider-
mis, and the ordinary products of the skin. The explanation was, I
believe, deemed imsatisfactory ; but it is supported by the later investiga-
tions of other cysts, especially of those to which I have already referred,
* Ueber Carcinoma alveolare und den alvcolaren Gewebsty pus ; in Henle and Pfenfer's
Zeitschrift, vii. 1849.
t Treatise on Diseases of the Testis, &c.
X Especially Nos. 2456 to 2459.
§ Medico-Chinirgical Trans., vol. xxvi. pp. 216 and 368. See, also, a paper by Mr. Cur-
ling, in the Monthly Journal of Medical Science, x. p. 1023.
jjf Jtfedico-Chirurgical Transaciions, vol. xxvU. p. 398.
BBMINAL 0T8T8. 851
growing in the thyroid and mammary glands. While we find in these
tint pcorfect gland-sabstance may grow from the cyst-wallsy it cannot
seem singular if , in a cyst lying near the testicle or its duct, materials
like the secretion of the testicle should be formed. The growth and
mtrition of gland tissue, and the formation of glandnsecretion, are so
truly parts of one process, that the truth of the former occurring in
one group of cysts removes all improbability from the belief that the
latter may occur in another group.
ISj then, we may regard these seminal cysts as autogenous, and may
amnge them with those of the kidney and other glands, which are de-
rired firom the transformation and overgrowth of isolated nuclei or
odb, they may supply some facts of interest to the general pathology
of cysts. Especially, we may observe that in different specimens of
tlieee ^'hydroceles of the cord," or in the same at different times, the
ocmtents may be either a seminal fluid or an ordinary serous fluid. In
one of the cases in which I dissected a seminal cyst, there existed, besides
that which contained seminal fluid, another larger cyst, above and sepa-
rate firom the testicle and tunica vaginalis; but this contained only serous
ftnd like that of a common hydrocele. Now this diversity is common
among cysts. Those in the kidney may contain the materials of urine,
but they more commonly do not; those of the lactiferous tubes may con-
tab either milk or some form of serous fluid ; ovarian cysts may at one
period produce hair and the other growths and secretions from skin, and
then, casting off these, they may produce only serous or some other fluid.
In different cysts, this diversity of contents may sometimes depend on
difference of origin or of early construction. But when it happens in
different periods of the same cyst, it illustrates the general rule that,
in the course of time, cysts are apt to degenerate, and to produce less
and less highly organized substances or secretions. This degeneration
does not take place in any certain time ; but generally, the larger a cyst
grows, the less organized are its products ; as if nearly all the formative
force were expended in growth, and little remained available for secre-
tion. (Generally, also, the longer a cyst has lived, the less organized are
its products. However, both these rules are only general. I met with
a remarkable exception to them in a seminal cyst, which had existed for
seven or eight years in a man more than 70 years old. I withdrew from
it eighteen ounces of fluid laden with seminal filaments ; and no fresh
accumulation took place in the two years follo¥ring the operation. In
another case of four years' duration, Mr. Stanley removed from a cyst
on the right side of the scrotum 25 ounces of such fluid, and from one
on the left side 46 ounces.
I have spoken of these seminal cysts as separate from the testicle and
tunica vaginalis. Mr. Lloyd believed that, in some cases, he obtained
fluid containing spermatozoa from hydroceles of the tunica vaginalis ; and
his belief was lately confirmed by the examination of a case after death.
The specimen presents the ordinary appearances of a common hydrocele^
852 COHPOUHD OE PBOtlVBBODB 0T8TB.
except that the inner surface of the tntuca vaginalia ia uneven, vith t
few email depressionB or poncbes from it. This hydrocele had leen n-
peatedly tapped ; the floid had always the ordinary serous appearum
of that of common hydrocele ; hot it always contained abundant wmiul
filaments. Can we suppose, then, that the tunica vaginalis has the povff
of secreting seminal fluid ? or, were there in this case minute weredng
cysts, which, by dehiscence, discharged their seminal fluid into the ctri^
of the tunica vaginalis, as sometimes ovarian cysts by spontaneotu open-
ings discharge their contents into one another, or into the cavity of i
parent cyst ? I am disposed to think this latter explanation the matt
probable; but as yet the facts are too few to justify any oonclniion.
LECTURE XXIIL
COHPOITKD OB PBOLI?EE0D8 GT8TS.
In the last lecture I traced and illustrated the formation of rimple or
barren cysts, — the cysts that have only liqoid contents. Among thcss,
the instances of the highest productive power appear to be in the cjiti
that secrete a seminal fluid, and those that are lined with a complete
secreting epithelium. In the present lecture I propose to describe tba
cysts that appear to have the power of producing more hi^ly organiud,
and even vascular, structures ; or, as they may be generally named, pro-
liferons cysts.*
These include such aa are often called "compound cysts," or "com-
ponud cystoid growths;" but I would avoid these terms, becsose theydo
not suggest the difference between
the cysts with endogenous growths,
and those that may appear eqnallj
compound, though they ftre only
simple cysts clustered or grouped
together. This difference sfaoold be
clearly marked in names, for it gene-
rally is so in natnre. In an ovaiy,
for example, such as is drawn in
Fig. 45, from a specimen in St. Bar-
tholomew's Museum, it is not onfre-
qnent to find many small cysts, formed, apparently, by the coincident
* Under this Dune ate h?re included the Kiro-cyBtic sarcomata of Sir R C. Bnxlie (Lec-
tures on Palliology am) Surgeiy) j miwt of the specinien* of Cyato-rarcoma phyltoilH and
proUrenim of Moller (On Cancer) ; and most of the tuberous i-jretic tiitnora of Mr, Ormi
Hawkina (Medical Gazette, vol. ixi. p. 651)
t Section of an orary with inany clo«elf.pl>i:ed cysta formed by eolaiEemenl of Giaaflan
VMicles: natund siie.
COXPLBX OVARIAN CYSTS. 858
enlugement of separate Graafian vesicles. These lie close and mntually
compressed ; and, as they all enlarge together, and, sometimes, by the
fisting of their partition walls, come into communication, they may at
leogth look like a single many-chambered cyst, having its one proper
nil formed by the extended fibrous covering of the ovary. Many mnl-
tlocular cysts, as they are named, are only groups of close-packed single
cysts; though, when examined in late periods of their growth, and, espe-
dally, when one of the group of cysts enlarges much more than the rest,
it may be difficult to distinguish them from some of the proliferous cysts.
Of the first formation of cysts that may be proliferous I need not speak ;
for, 80 far as is at present known, they may be formed exactly as the
barren cysts are. A cyst may be proliferous in whichever of the plans
described in the last lecture it may have had its origin. Thus, 1. Bursse
formed by expansion and rarefying of areolar spaces may be found
with organized, pendulous, or loose growths from their walls.* 2. Among
the cysts formed by growth of natural cavities or obstructed ducts, we have
instances of surpassing proliferous power in the ovarian cysts from
Graafian vesicles, and of less power in some cases of dilated lactiferous
tubes and dilated veins.t And 8. Among the autogenous cysts we find, in
the breast and other glands, some of the principal examples from which
the following history of proliferous cysts will be derived.
The account given in the last lecture of the modes of origin of barren
ejBts may therefore, so far as the cyst is concerned, suffice for the pro-
liferous ; and I shall now need to speak of only the intra-cystic produc-
tions, the difierences of which may decide the grouping of the whole
division of proliferous cysts.
1. The first group includes the cysts which have others growing in or
upon their walls. Of these, two chief examples are presented, in the
complex ovarian cysts, and in the cystic disease of the chorion or
"hydatid mole."
The principal varieties of the complex ovarian cysts have been de-
scribed to the very life by Dr. Hodgkin, to whom we are indebted for
the first knowledge of their true pathology^. But, since his minute
description of them is, or should be, well known, I will more briefiy say
that according to his arrangement, we may find in these proliferous
ovarian cysts two principal or extreme forms of endogenous cysts ;
namely, those that are broad-based and spheroidal, imitating more or
lees the characters of the parent cyst, and those that are slender, pedun-
colated, clustered, and thin-walled. Between these forms, indeed, many
* Muaeum Coll. Surg., 367, &c. See also a case, by Mr. Cspsar Hawkins (Medical Gazette
Tol. xxL p. 951). Perhaps, also, tbe case may be here referred to, in which Mr. Hunter
found loose bodies in a cavity formed round the ends of the bones in an ununited fracture
(Museum Coll. Surg^ Nos. 4C9, 470).
t Muaeum of St. Bartholomew's Hospital, Appendix 10; and see last lecture, p. 348.
^Med.-Cliir. Trans, zv. 25G; and Lectures on the Morbid Anatomy of Serous Membrane,
p. 221, etseq.
28
864
COUPLBX OVARIAIT OTBTB.
transitional and many mixed forms may be found ; jet it i
to distinguish the two extremes.
A typical example of the first is in the College Mnseum,* and k
sketched in fig. 46. It is an Hunterian specimen ; and the mode of jn-
paration shows that Mr. Hunter had clearly apprehended the peouIiuitiH
of itfl Btrncturc. It is a large cyst, with tough, compact, and lamttut^d
walls, polished on both their surfaces. On its inner surface there project,
with broad bases, many smaller cysts, of various sizes, and Tariondj
grouped and accumulated. These nearly fill the cavity of the parent
cyst ; many of them are glo-
bular ; many deviate ^om the
globular form throogh m>-
tual compreBsion; and widm
many of them are similar bit
more thinly-walled cyste of ■
third order.
Here the endogenous ej^
projecting inwards, appear to
have nearly filled the cin^
of the principal or pirait
cyst ; and this filling up ii
complete in another speciiMi,
in which there remaina, indie
middle of the parent tjti,
only a narrow space honnded
by the endogenous cyats con-
verging in their growth from
all parts of the parent walls-t
For a typical example of the
slender, thin-walled, pedun-
culated, and clustered form of endogenous cysts, I may adduce the speo-
men from the Museum of St. Bartholomew's Ho3pite],§ which is draim
in fig. 47. It shows part of tho tbictc laminated wall of an ovarian ^st,
the inner surface of which is thickly covered with crowds of pyriform
and Icafiike pellucid vesicles, heaped together, and one above another.
This is a comparatively simple specimen of the kind: in the more con^
plcx, the endogenous cysts or vesicles are multiplied a thousand-fold,
and clustered in large-lobed and warty-looking masses, that nearly fill
the cavity of the cyst. Specimens of this kind are among the most
valuable possessions of the Museum of Guy's Hospital.
Tho College Museum furnishes specimens of the forms intermediate
• No, 166.
t Fig. '16, section ofa prolireious a
□ cyst, ileKribed in the tezl : sboot one-Iliinl of ibo
COHPLIZ OTARIAir CT8TB. 856
htween theee extremes,* in which the endogenous cysts of the seoond and
tkiid ordera hftve walls that
ire not pellncid, yet are thin Fig.«.t
md rascnlar, and are attached
ij pedioleB rather than by
Irotd bases. Mixed forms are
ilao found,! i° which the parent
ejat-vall bears, at one part, oral
md spherical membranous cysts
dtreloped beneath its lining
nambrane, which they raise in
lov OQUTex projections into its
ari^; and at another part,
pm^ of small leaflike, nar-
nwly pedoncnlated, uid pen-
Adons cysts. And ag»n, the
uu prolific power which is
dunni in tiiese endogenous con-
nrging cysts, is often, in the
Hme specimens shown in exo-
^ous growths ; similar cysts,
ongly or in clusters, projecting
from the exterior walls of the pare&t.§
But ft lecture would not suffice to describe, even briefly, the variety of
forms into which these ovarian proliferous cysts may deviate. Whether
we regard their walls, the arrangement and shape of the endogenous
cysts, their seats and modes of origin, their various contents, and the
yet greater dificrences engendered by disease, they are so multiform,
that even imagination could hardly pass the boundaries of thoir diversity.
It most suffice to refer to Dr. Hodglun's works for an elaborate account
of the structure and arrangement of the cysts ; and to the essays of Dr.
Tfltjl for descriptjons of their contents.
The foregoing account of the structure of these cyst-bearing cysts in
the ovaries is derived entirely from naked-eye observations. Respecting
the mode of generation of the endogenous cysts, it could only be sup-
posed that they are derived from germs developed in the parent cyst-
walls, and thence, as they grow into secondary cysts, projecting into the
parent carity ; or, disparting the mid-layers of the walls, and remaining
quite enclosed between them ; or, more rarely growing outwards, and
projecting into the cavity of the peritoneum.
• No*, les A, and les B,
t Fig. 47, part of the wrII of a pToIiferoua o'
j No. 2621.
j Na 2623 in Ibe College MuKuni presents
dkkIm of growth in the same specimen.
I Lancet, 1B49.
n cyst, described above; naiuial size,
ismncc of the endogenoua aad exogenous
S56
CT8TIC DI8BASB OF THI OHOBION.
Sut a more complete illustratioa of the orij^n of such secondary c^
and a good confinnitkn
of what I have ten
describrng, msj be
drawn from Dr. Metto-
hcimer'e mvestigatkiiii
on the microscopic itriK-
ture of the cystic dis-
ease of the ehonOD-t
Some of his iUnstratiou
arc copied in fig, 49,
The general ciant-
ters of thia disease, con-
stituting the hydatid
mole, are well knoiD.
A part, or eren Ibe
whole, of the chorion ii
covered with pellndd
resicles with limpd eon-
tents, borne on kmg
slender, and oftcB
branching pedicles (i)-
The cysts are usdbHj
oval or pyriform ; their
vails are clear, or We
en B minute, opaque dots (l)l
they may be simple, or may bear others projecting from their walls.
Dr. Mcttenheimer has found that the minute dots besetting these cysti
are villous processes, exactly resembling those of the natural chorion,
and growing from the walla of the cysts, either outwardly or into their
cavities. In these villi he traced the development of cysts. In thar
natural state the villi may be described as filiform or ctavate processes,
often branching and bearing bud-like projections, and composed of dimly-
granular substance, in which are imbedded minute nucleated cells (c).
In this cystic disease, vesicular bodies may be seen (as in D and b) sca^
tered among the cells in the villi, which bodies are distinguished &om
the cells by their pellucidity, their larger size, and, when largest, bj
double contours ; but, from the cells to these, every gradation may be
so traced as to leave scarcely a doubt that the vesicles are derived from
cells deviating from their normal characters. Thus, in some of the eella,
* Fij!. 48, cyaxic disease of ilie chorion, as de<crib«i1 above: a and B, natural size; c, D,!,
mnEnified 250 lim».
t Mailer's Arcliiv, ISSO, H. v. p. 417. His account, tbouKli diOerenl in interprelalioa, it
consislent, as lo faclg, with one liy Gicrse and H. Meckel, in llie Veihandl. dei GeacllKh.
IQi GebartsfaQlfe in Berlin, 1847.
CTBTIG DI8SA8B OF THE OHOBION. 85T
die oontentB are Been lighter and less granular ; in some they have
ntiietj disappeared without increase of size ; and then, when their con-
tents are thus become nniformlj pellucid, and they have acquired the
duuracter of vesicles, the cells appear to grow, while their walls become
stronger, and they acquire such a size that they are recognised as very
smaD cysts, similar in all but their size, to those which are visible to the
mled eye.
Now, though this method of formation of cysts has been traced by
Hettenheimer only in the villi which grow in the cysts themselves, and
therefore, so to speak, only in the production of cysts of the second and
liter generations, yet there can be little doubt that the first cysts in the
diseased chorion are formed in its own villi after the same manner. For
the villi which are borne on the cysts, and which to the naked eye
Vff&tii like little dots, are, in all essential characters, like those natural
to the chorion ; and the cysts of all generations are equally like. The
▼hole process may, therefore, be probably thus described : — Certain of
the cells in the proper villi of the chorion, deviating in their cell-form,
and increasing disproportionately in size, form cysts, which remain con-
nected by the gradually elongated and hypcrtrophied tissue of the villi.
*^0n the outer surface of the new-formed cysts, each of which would, as
it were, repeat the chorion, and surpass its powers, a new vegetation of
Tilli sprouts out, of the same structure as the proper villi of the chorion.
h these begins again a similar development of cysts ; and so on ad infi-
ftiitem." Each cyst, as it enlarges, seems to lead to the wasting of the
cells around it ; and then, moving away from the villus in which it was
formed, it draws out the base of the villus, which strengthens itself, and
forms the pedicle on which the cyst remains suspended.
Such is the account of the minute structure and formation of the
cystic disease of the chorion ; and perhaps no instance could afford a
better confirmation of the production of cysts by the enormous growth
of elementary cells, or a better type of the capacity of cysts thus formed
to produce structures resembling those in the abnormities of which them-
selves originated. A similar capacity is among the characters of all
the cysts of which I shall next have to speak.
2. I pass now to the consideration of the cysts that are proliferous
with vascular growths from their internal surfaces.*
* It may be well to refer to the fact that abnormal growths upon natural free surfaces
commonly affect the same forms as will bo described in the following account of the vascu-
lar growths in cysts. Tlie chief forms are three: namely, 1st, groups of slender, small, and
pedanculated bodies; 2d, larger round pendulous masses; 3d, nearly level, slightly elevated
layers, such as granulations. Now groups of pedunculated leaflike processes occur on
natural free surfaces, in tlie growths that are so frequent in chronic rheumatic diseases
of joints, from some of which MQller draws his account of /t/xrnia arboretcens ; in certain
warty cancerous growths on the skin, which appear like cancerous overgrowths of the
papilla; and in similar growths in the larynx about the vocal cords. Of the larger, round,
pedunculated masses growing on natural free surfaces, instances exist in the medullary
cancers of the urinary bladder, the polypi of the intestines and stomachy the \)enduIou3
358 PBOLIFEROUB MAMMABT 0TST8.
The first group of them may include those that bear glandular growths
— the ^^ glandular proliferous cysts," as we may call them, because the
minute structure of the substance growing into them is, in its perfeel
state, exactly comparable with that of a secreting or vascular gland.
Such cysts form part of the group to which the name of ^^ sero-cjBtie
sarcoma" was given by Sir B. G. Brodie, who first clearly distingoiBhed
them."*" They are also part of those which furnished to Dr. Hod^
the chief grounds for his well-known theory of the formation of solid
tumors — a theory which, in regard to at least these growths, has good
foundation.
The chief seats of the formation of glandular proliferous cysts are
the mammary and thyroid glands. Their history in the thyroid, in
which their formation scarcely passes the bounds of health, is amply
illustrated in the often cited works of Frerichs and Rokitansky, to which,
as well as to the essay by Mr. Simonf on the natural structure of the
gland, I must, for brevity's sake, refer.
A series of preparations,^ such as are represented in figs. 49, 50, 51|
may clearly illustrate the corresponding process in the mammary gland;}
but here the conditions are far more remote from the normal type. If
we may believe that a series of specimens may be read as the continwnifl
history of one case, because they seem to present successive phases of
the same disease, then, we may suppose, first, the existence of a cyit
(fig. 49), or of a collection of cysts (fig. 51), in the mammary gland.
Such cysts may be formed by the dilatation of parts of ducts ; but, mtieli
more commonly, the cysts that bear vascular growths are derived through
transformation and enormous growth of some elementary structure of the
gland. 1 1 So far as I know, there is nothing peculiar in the structure of
the mammary cysts that may be proliferous. They are usually ovoid or
spherical, unless changed by mutual compression, as in fig. 51 : they
usually appear formed of thin fibro-cellular tissue, with or without elastie
fibres : they have abundant bloodvessels, and are closely adherent to the
surrounding parts : their walls are peculiarly apt, in disease, to become
oedcmatous, succulent, and almost gelatinous. They may grow to an
enormous size. A specimen is in the Museum of St. George's Hospital,
in which a cyst, that would contain more than two pints of fluid, has
outgrowths of the skin ; and of tlie flatter, and more nearly level layers, the condyloniatous out-
growths of skin, the epithelial cancers of the stomach and intestines, and the cheloid growths,
oi\en afford examples. There is in all these resemblances a good illustration of the ten-
dency of the growths in cysts to imitate those on natural parts. (See tlie sixth note under
the heading of Villous Cancer, in Lecture xxxiii.)
* The disease is admirably illustrated by the specimens in the Museum of the College,
and in those of St. George's, Guy's, and St. Bartholomew's Hospitals.
t Philosophical Transactions, 1844, Part ii.
J Such as those in the College Museum, Nos. 108 to 172, &c.
§ All the cases recorded have occurred in ihe female breast, except two : one by Mr. Ar>
noit; Medical Gazette, xxii. 378: and one by MOller; "On Cancer," p. 180.
fl On the difference between the solid contents of dilated ducts, and those of the proper
oi autogenous cysts, see Mr. Birkett^s account in his £:<say on tlie Diseases of the Breast.
i
1
I
PROIiIIBKOVS HAUKABT 0TST8. 358
lame lowlj lobed growtha from one portion of ite mner Burface ; one in
Hia College Mnsenm, remoTed b; Mr. Listen, weighed twelve pounds ;
■nd Dr. Warren relates a case in
Thick lie remoTed a tmnor of this ^^' *"'*
kind of thirteen ponnds weight.
The cjrsta ma; contain any of the
Tirifties of Beroos or bloody fluid,
deu or turbid, that I described in
the last lecture.
Now, from some part of the in-
Der lorface of such a cyst, » vas-
enlir growth may spring (fig. 49) ;
ind, u this gradually increases at
1 nte beyond that of the increase
Df the cyst, it fills more and more
of the cavity. At length, the
growth wholly excludes the fluid
eimtents of the cyst, and its sur-
fieee come in contact with the remainder of the cyst-walls (figa. 50, 51).
Hie growth may now coalesce with the walls of tiie cyst, and form one
lolid tumor, enclosed in and connected with them, Just as ordinary solid
tomon are invested and connected with their fibro-ccUular capsules. Or,
groving yet further and more rapidly, the growth, hitherto intrar<;ystic,
may protrude through its cyst-walls and the superjacent integuments ;
jirotrading through them
is a hernia of the brun
does through the skull,
growing exuberantly over
the w^acent skin (fig.
51), iuid, like such a
bemia, reproduced when
cut away.
The time in which
these changes may be
accomplished is extremely
various. Usually, the in-
crease of the intra-cystic
growth appears to be
piunless, and it may be
very slow: ten years or
more may pass with little changi
ng.M.t
; but the increase is generally faster.
■ Fig. 49, a eyi\ in ■ mBinmKrjr gland, K> part of the inner luifuce of which a vskuIbi
grovlh 19 BttKched. Below it s xnaller cyn is neaily filled wilh a similar grawlb. Miu.
St. Bartholomew '■ : ihree'rouiilis of Ibe natural gizc.
t Fig. 50, a cyst in the mammary gland filled wilh a vaKular growth bearing clusters ol
pedunculated processes. Mun. Coll. Surg. Nnliiral size.
860 PEOLIFBBOtIS XAHHABT OTBTB.
and it often shows an accelerating rate ; ao that, late in the diaraw,
progress is cxtremelj quick, even quicker than that of moat
growths.
The characters of the intra-cystic mammary groirthA are
not only according to our obscrrations of them at different
of their existence, but, apparently, even from their vety orifdn. k
looking through a largo scries of them vhile they are stiU in i
periods of their development, we may reduce them to these <Ud^
forms ; namely, low, broad-baaed, convex layers, like coarse gnaah
tiouB ; spheroidal, lobcd, and nodulated masses, cauliSower-like, attacM
by narrower bases (fig. 49) ; masses or clusters of pedunculated leilib'
processes, slcudcr, single or varioualy branched, and interlaced ia il'
possible forms (fig. 50) ; masses of firmer and much paler gubstance, i^
pearing aa if formed of close-packed lobes, or fimbriated proceoMS, V
involuted layers (fig. 51).
In apparent structure, also, the varieties of these growths are tetn^
less numerous. Some of them are opaque, yellow, and soft, yet elutic;
and rather tough, so as to bi
"■-**-* separable in laminee like fibria»
clot; others are more VHCthi^
succulent and spongy, like gna»
lations ; others are like Istm
and masses, or heaped-np hym,
of gelatine, not firmer than liie^
or even like vitreous humor, neld-
ing a tenacious synovia-like finid;
others arc firm, compact, ncaHj
pure white, imitating the mua-
mary gland, but not succulent.
To these varieties of appeanaet
we might add yet more, dne eitW
to diverse shades of yellow, pink,
gray, or purple ; or to the varioM
clustering and incomplete fuliMi
of the cysts; or to the increafiif
firmness of the growths, and theif
fusion with the cell-walla ; or t*
the development of new barren or proliferous cysts: in the wW
growths that now fill the cysts of a former generation ; or to varioa
changes of decay or disease ensuing in either the cyst-walla or tbe'ir
contents.
It would be too tedious to describe all these varieties, especially while
we do not yet know whether, or in wliut degree, these forms are related
* Fijt. 31, collection of tyut filled willi RlandulM giowdu in and protruding fnim At
mamniary gland : dncribed p. 3lil. Half iha natural aiie.
PB0LIFER0U8 MAMMARY 0Y8T8. ' 861
to one another, or to any one typical condition of the intra-cystic
growtha.
Respecting their minute structure, we have good guidance in the pro-
hability, which will be supported in the twenty-eighth lecture, that the pro-
per mammary glandular tumors — ^the chronic mammary tumors of Sir A.
Cooper — ^have their origin in intra-cystic growths, transformed into solid
tmors in the manner just described. The mammary glandular tumors
are oompoeed of minute structures closely imitating those of the gland
itsdf. They present microscopic lobes, and fine tubules, lined or filled
iridi nuclei and nucleated cells, like those of secreting organs ; these,
indoeed within pellucid membrane, form a pseudo-glandular substance,
BBck as, we might suppose, needs only a main duct to enable it to dis-
oharge the office of a mammary gland. In the like manner and degree,
in some specimens in which the cysts and their contained growths are
itQ] easily separable, we can discern in the growths a likeness to the
mammary gland itself in their minute structure.
These facts have been observed especially by Mr. Birkett, and were
ferjwell marked in a case which I was recently able to examine, and of
which figure 51 represents a section. It was a very large protruding
tmnor of the breast removed by Mr. Lawrence from a lady 55 years old.
It had been observed for thirty years, remaining like a small knot for
twenty-six years, and then slowly increasing, till, at the end of five years,
a red, fungous mass protruded from the breast, bled freely sometimes,
and discharged profusely. This, too, increased quickly, and was painful,
lie whole breast was removed, and the patient recovered.
The tumor (fig. 51) measured nearly seven inches by five. The part
which did not protrude beyond the level of the skin was imbedded in the
mbfitance of the gland. It consisted of numerous lobes of various sizes
and shapes, and variously divided into smaller lobes ; all being evidently
fonned of distinct cysts closely packed and compressed together. Most
of these cysts were filled with intra-cystic growths ; yet in many of them
it was easy to pass a probe between their walls and the surfaces of their
contained growths, which were fixed to only one part of the cyst-walls*
In the protruding part, of which the overhanging outer border is shown
^ the sketch (fig. 51), the same general plan of structure could be dis-
cerned, but less distinctly.
Among the solid growths that filled the cysts, some showed clavate^
dose-packed lobes ; some were nearly simple ; nearly all were pale, white,
gf^yish or yellowish, and smooth and shining ; a few were spotted with
yellow, from degeneration of their tissue. Repeated examinations showed
^t all these consisted essentially of a tissue imitating that of a gland,
^^i such as will be described in the twenty-ninth lecture. The edges and
^aces of the examined portions were minutely lobed or acinous, like ter-
Diinations of gland-tubes. These were inclosed by well-defined, pellucid
5»embrane ; and their cavities were full of nuclei and nucleated cells, like
862 PBOLIFBBOUS MAMMARY CYSTS.
mammary gland-cells, with some granular matter. Except in that thcae
acini led to no distinct ducts, but seemed confusedly lieaped together, the
imitation of gland-structure was complete.
Now the glandular nature of these growths in the best-marked cases of
proliferous mammary cysts, and the probably constant relation of the
mammary glandular tumors to them, as well as the analogy of the intn>
cystic thyroid growths, may seem to make it probable that, in all casee,
the growths within the mammary cysts are of essentially the same glan-
dular nature, and that their various appearances are due to their being in
rudimental, or degenerate, or diseased states. But we cannot be sure of
this. In three cases, in which I have minutely examined soft intra-cysde
growths, I could not recognise a glandular structure. In all, I found a
basis-substance, which was pellucid, soft, and in one case diffluent ; it had
little or no appearance of fibrous structure, and no distinct fibres, but,
rather, presented the uniformity as well as the consistence of soft gela-
tine. In it, as in a blastema, were imbedded nuclei and cells, wbidi
chiefly presented the forms of developing fibro-cellular tissue, like thoie
in granulations, or of inflammatory lymph : or their forms might be
explained, I think, by the disorderly conditions of their production and
development. Nearly similar, and equally indecisive results appear from
an accurate observation of such a growth by Dr. Mettenheimer,* and
from two cases related by Bruch.f
Perhaps we may conclude that, in these specimens, the intra-cyatic
growths were in a rudimental, or in a morbid state ; that the general
destiny of such growths is towards a glandular structure, but that in these
and the like instances they fell short of it, or swerved from the right
course. But I would rather not form any conclusion at present. These
are just the cases of which, as yet, the interpretation is scarcely possibki
while we are ignorant of the changes that may ensue during development,
degeneration, and disease.
I have said that the mammary and thyroid glands might bo regarded
as the elected seats for cysts having glandular growths ; but they are some-
times met with in other parts, as in the prostate, and, I believe, also in
the lip. In the Museum at St. George's Hospital is a tumor removed
from a man's upper lip, in which it had been growing, without pain, for
8i years. One half of it is a cyst that was filled with a thin flaky fldd,
and was thought to be a dilated labial gland-duct ; the other half is a
solid tumor, just like a glandular tumor of the lip which I shall de-
scribe in a future lecture. I have lately seen another case with nearly
the same characters: and the combination of a barren cyst with a proli*
ferous one, which they seem to illustrate, is not rare in the mammary gland.
• Mailer's Archiv, 1850, p. 207.
f Die Diagnose der bOsartigen GeschwQlstpf p. 185, 1
91.
VARIOUS PBOLIFEBOUS CYBT8. 868
In the same Museum is a cyst, with a broad vascular growth, like grann-
Isdoiis, firam its walls, which was taken from a girl's labium by Mr.
Coder. It has a small external opening, suggesting that it may have
had its origin in a cystic mucous or sebaceous gland.* In the College
Huseum, No. 167, is a thick-walled cyst, from the cheek of an old woman,
ihich contains two large, lobed, and pedunculated masses, so like some
rf those found in the mammary cysts that we can hardly doubt their glan-
dular nature.
All these specimens, however, need more minute examination; at
present they only make it probable that any cyst originating in or near a
secreting gland may be the parent, or the habitation, of an endogenous
gbukdular growth.
To this account of glanduliferous cysts it must be added, that their
ehiracters may be closely imitated by cysts formed in parts altogether
onooimected with secreting glands. It is not, indeed, probable that the
oontamed growths in such cysts are glandular ; yet they present charac-
ten like the softer growths that are found in the mammary cysts.
I found one of these proliferous cysts beneath the gracilis and adduc-
tor longns muscles of a woman 25 years old. It was a large spheroidal
miss, which felt as if held down tightly on the front of the pelvis, and had
pahed the femoral vessels a little outwards. It lay too deep to form a clear
diagnosis of its nature ; it was assigned to no distinct cause ; it had been
iK)ticed for only seven months, but when first seen was '^ as large as a tea-
cup." I removed it without much difficulty ; for it was not closely adhe-
rent to the parts, except to a small portion of the front of the pubes,
ihere it rested on the adductor brevis. The patient has since remained
weU for more than three years.
The tumor was spheroidal, about four inches in diameter, and consisted
chiefly of cysts, from two of which six or eight ounces of turbid serous
fluid escaped when they were cut across. One of these cysts was thickly
lined ^th pale, brownish, fibrinous substance, like that which one finds in
old hasmatoceles ; and this appeared as fibrine on minute examination.
'^iM)ther was nearly filled with a ruddy mass, in most parts soft and suc-
<^cnt, like blood-stained gelatine. Much of this mass was also like
fihrine-clot, with abundant corpuscles ; but the layers of it next the cyst-
^^ were firmer than the central parts, and contained all the forms
uiat one finds in common granulations developing into fibro-cellular tissue,
■"^e microscopic likeness to granulations was, in these parts, exact. The
'^ of the tumor, including some large portions between the cysts, con-
8J8ted of fibro-cellular tissue more or less perfectly developed, f
* See also nn account of a specimen in the same Museum, by Dr. Hawkins : Medical
^■wtte, xxi p. 951 ; and Pioc. of Pathol. Soc. ii. p. 340. I suppose there is some rolntion
'^^^Ween these and the subcutaneous warts and condylomata described by Hauck and Kra-
^^r; but 1 have not seen what they refer to. (See Simon: Hautkrankheiten, p. 225.)
t The tumor is in the Museum of St. Bartholomew's Hospital.
864 RBCUBBINQ PBOLIFBROUS CT8T8.
A similar tumor was removed by Mr. Lawrence from the exadlj
responding part of a woman, 50 years old, in whom it had grown
and without pam, for nine or ten years. It gave the sensation of a
fatty tumor, as large as an egg, but when removed was found to be
bilocular cyst. Each cavity contained, together with serous fluid,
reddish, gelatinous-looking mass, like a polypus in one, and solid uin
folded in the other. The cyst-walls were tough, pure white, fonncdrfl
fibro-cellular tissue, and polished on their inner surface. The intrm-cjili^:
growths consisted of a structureless or dimly-granular or fibriOatim
blastema, with abundant oily molecules, granule-cells, and corpoide^
like nuclei or cytoblasts, imbedded in it.
And to these two instances, since the disease seems very rare, I b^,
add a third. A girl, twenty-three years old, under the care of I^Ir. Li»
rence, had a pyriform pendtdous tumor in her neck, about 2^ inches ka^
Its surface was ulcerated, livid, and painful, and bled occasionalW. b
history was doubtful ; but it had existed for at least a year. On renofi^
it appeared to have grown in the subcutaneous tissue, and to be componl
of a collection of cysts, closely and irregularly packed, and, for the mH
part, filled with lobed, soft, cauliflower-like growths from parts of thdr
walls. It closely resembled, in its general aspect, the collections of pi^
liferous cysts, with soft intra-cystic growths, in the mammary gland. Ii
microscopic structure the intra-cystic growths appeared composed endrdf
of corpuscles, like those of lymph or granulations : but my record of tk
examination, made several years ago, is too incomplete for a clear aceool
of them.
I believe that all the cysts that I spoke of, before these that coouii
vascular growths, may be regarded as completely void of the charactof
of malignant disease ; at least, I have met with no evidence contraiy ti
this statement, except in certain cases of proliferous ovarian cysts, to
which I shall presently refer. And, in general, the reputation of iiiiio>
cency is deserved by the glandulifcrous cysts also. Yet there are ctfei
which show that such tumors may have an exceeding tendency to recvr
after removal.
A healthy, robust woman, 37 years old, was under Mr. Lawrencei
care with a very large protruding tumor in her right breast. This hi
been slowly increasing for ten years, but, till lately, had given little «•
easiness, except by its bulk, and had not hindered her nursing. Mr. Liw-
rence removed the greater part of the breast and the tumor in 1844. It
weighed 7^ pounds, and was a well-marked example of that fom of
" sero-cystic sarcoma," in which the cyst-walls, if altered by inflanuBi-
tion, or imperfectly formed, are soft, succulent, and glistening, with soU
growths of similar substance, lobed and fissured. Many cysts in it stiB
contained serous fluid. Its appearance when recent, and even nov tf
preserved,* leaves no room for doubt as to its nature.
* In the MuMuni of St. BBrtholomew's, Ser. 34, Not. 10 and 20.
RBOURRIKa PROLIFEROUS CYSTS. 865
The patient remained well for fifteen months ; then a tumor began to
grow under the scar, and qnicklj increased. After nine months' growth
Mr. Lawrence removed this also, with all the surrounding tissues. It
tru a pale, pinkish, and yellowish mass, like soft size or jelly. It was
kibed and folded, and induded some irregular spaces, containing a fluid
Ske mucus or half-melted jelly. It n^as like the solid parts of the tumor
hst removed, and consisted of a pellucid dimly-fibrillated blastema or
buis-eubstance, in which were imbedded nuclei and abundant granule-
eellfl, of various forms. The sketches and account of these, which I drew
It the time, make me still sure that they had none of the characters of
eincer-cells, but were like nuclei or cytoblasts of ordinary form, or elon-
gated, many of which were changed by fatty or granular degeneration.
After this second operation, the patient remained well for seven
months, and fully regained her stout, robust appearance. But now
a third tumor appeared; a fourth soon after; and both grew rapidly, till,
ifter two months, Mr. Lawrence removed them, and all the parts bound-
ing them. They were, in every respect, exactly like those removed in
the last operation, and near them lay another not discerned before the
removal. Erysipelas following this operation proved fatal, and no post-
mortem examination could be obtained.
Now in the first of these operations some portion of the mammary
gland was left. It is possible that some cysts already existed in this
portion, and were subsequently developed into the second tumor, which,
Aerefore, might not deserve to be called a recurring tumor, although,
indeed, it appeared under the scar of the former operation, and not in
the place where the gland was left. But, after the second operation,
there is little probability that any gland remained, and we may, with
u Ettle doubt, regard the third tumor as an instance of recurrence or
repetition ; t. e. of reappearance of the disease in an entirely new-
growth.
Sir B. C. Brodie* has related two cases of single recurrence of tumors
^ery closely resembling that just now described ; and the liability to
'ecorrence which Mr. Lawrence's case presented is surpassed by one
'■^corded by M. Lesauvages,t whose description of the tumors he re-
moved accords so closely with what was observed in the foregoing case,
^at I can have very little doubt they were of the same nature. The
Patient was 63 years old. The first tumor of the breast, which was of
S^&t size, was removed in February, 1832 ; a second appeared, and was
Removed before the healing of the first wound ; a third in May ; a fourth
Ui September of the same year; a fifth sprang up, and was removed
in February, 1833 ; a sixth in May ; in a seventh operation, in June of
the same year, three tumors were removed ; but from the same spot two
i&ore arose, and these grew rapidly, and the patient died.
• Lectures on Pathology and Surgery, p. 145.
t Archives G^n. de M^decine, Fdvrier 1844, p. 180.
866 BECUBBINa PR0LIPEB0U8 0T8T8.
Now, if, as I believe, all these cases were examples of the proliferoa
cystic disease of the breast, they prove such an inveterate tendency to
recurrence in this disease, as is scarcely surpassed by any even of tbe
well-marked malignant tumors. Unfortunately no examination of dtlur
case was made after death ; so that it is not possible to say whether thi
more characteristic features of malignant disease existed, such as theotm-
currence of similar disease in internal organs. The same defect does not
exist in a most remarkable case related by Dr. Cooke.* The patieDt
was about 40 years old when, in April, 1847, six ounces of a glairy brown
fluid were drawn from a cyst in her breast, which formed part of a large
tumor that had been growing for seven months, and felt in some purtB
firm, in others soft and fluctuating. Occasional tappings were sabse-
quently employed ; but after five or six weeks the integuments inflamed
and sloughed over the cyst, and a profuse discharge of similar glurj
fluid ensued. '^ Fungoid masses" soon protruded, and in July, 1847, Dr.
Cooke removed the whole disease. It weighed 8^ pounds, and con-
sisted of fungoid masses of various degrees of firmness, with a oratnl
cavity lined by a vascular membrane. In December of the same year,
a small enlargement on the scar was removed. In March and in October
of the next year (1848), renewed growths were again removed. In 1849,
the disease again returned, and was extirpated in June, 1850. This ma
^^a miniature representation of the tumor removed at first:" and it ma
examined by Mr. Birkctt, who reported of it, that, '^in a stroma of
fibrous tissue cysts appeared, containing a yellow tenacious fluid. The
follicular terminations of ducts of glands were very distinctly seen in
the fibrous tissue, and nucleated corpuscles : within these follicles were
clearly seen the elements of the epithelium of glands." The patient
recovered rapidly from this last operation, and no recurrence of llie dis-
ease in the breast again ensued ; but in June, 1851, she began to suffix
with what proved to be cancer of the peritoneum, liver, pleura, pelvic
organs, and lumbar and thoracic lymphatic glands. When she died, in
November, 1851, abundant cancerous disease was found in all these parts:
but the seat of former disease in the breast was healthy, and, as Mr.
Birkett especially remarks, all the lymphatic glands connected with the
breast were, as they always had been, unafflBcted, while all those connected
with the cancerous parts in the pelvis and elsewhere were the seats of
cancer.
The fact last mentioned makes it improbable that the cancerous dis-
ease with which this patient died was continuous with, or a part of, the
disease which had been manifested in the breast. Rather, we may be-
lieve that the two afiections were essentially distinct, and that the first was,
like the others I have related, an example of recurring proliferous cystic dis-
ease. But farther inquiries are necessary to elucidate these cases ; at pre-
sent, they are obscure in all but their practical import, and in their proof
• Medical Times and Gazette, August 7, 1852.
OAKOSROnS PROLIFEROUS 0TST8. 867
X the cystic disease of the breast, though generally a completely inno-
it disease, is, in certain cases, peculiarly prone to recur after removal.
ich inquiries, I may add, would be likely to obtain knowledge on
feral important but unsettled points in relation to the whole class of
mors ; such as (1) whether any, and what, tumors may be regarded as
ansitional, or intermediate, between the innocent and the malignant;
E) whether tumors which, though having the general characters of
nocent tumors, are yet apt to recur, may not in their successive recur-
noes, assume more and more of both the structure and other properties
f Cftneers ; (8) whether tumors, like such as are generally innocent, are
Mt peculiarly prone thus to recur in persons who are members of can-
HTOos families ; (4) whether there is not peculiarly near affinity between
forms of these proliferous cysts, and the alveolar or gelatiniform
icer. Such an affinity is made probable by some of the diseases of
dbe ovary. In some of these, it is difficult to decide to which of the two
ifections they should be referred : in some, what seems to be a oom-
|kz cystic disease of the ovary is coincident with medullary cancer of
ftfi same or other parts;* and in some, medullary or alveolar cancer
'Meins to be developed in the interior of portions of the complex cysts.
I shall consider these questions more fully in the lectures on the general
ftihology of cancers.
8. It may be inserted here, that the mode of growth observed in the
f^dular proliferous cysts may be imitated by genuine cancerous
diseases.
Cancerous growths may be found in cysts under at least two condi-
tkms ; namely, in cysts that of themselves appear innocent, and in cysts
induced within cancers.
Of the former mode of growth we have the examples in ovarian cysts,
to which I just referred ; and herein are, perhaps, the only unexception-
lUe instances of the transfonnation of an innocent into a malignant
tmor.
The second mode of production of intra-cystic cancers is best shown
11 Boine examples of medullary tumors of the testicle. In thesef we
Hy see a repetition, so far as the plan is concerned, of the intra-cystic
ptodnction of thyroid gland. The great mass of the medullary disease
includes smaller masses, incapsuled with fibro-cellular tissue, and com-
monly presenting a lobed and laminated form, at once reminding us of
dtt intra-cystic glandular growths, and justifying the application to them
rf the principles of Dr. Hodgkin*s theory of the growth of cancers.
In these medullary testicles the intra-cystic medullary growths have
'■ttlly filled the cysts and coalesced with their walls. In rare cases one
' Thii was the case in the patient whose history was last mentioned, and the same fact
"** been freqaentlj observed,
t ib in Mas. ColL Sarg., Na 2396.
868 CUTANBOUS PR0LIFBB0U8 0T8TB.
can discern how the growths spring up as spheroidal, or as pedunculated,
branching, and grouped processes from the interior of the cysts. Thii
condition was peculiarly well shown in a case of cancer of the clitoru,
in which the whole of that organ was occupied or concealed by a callce^
ous mass inclosing several distinctly walled cysts, which were half-filled
with small, soft, and lobed cancerous intra-cystic growths.*
4. I proceed to the consideration of the ctUaneoua prol\ferou8 eytU;
i. e. of cysts within which, in the typical examples, a tissue grows, hif-
ing more or less the structure and the productive properties of the skiiL
Instances of these in a perfect or typical state are rare. In the large
majority of cases the cutaneous structure, if it were ever'' present, has
degenerated or disappeared ; and we recognise the relations and import
of the cysts only through their containing epidermal and sebaceous ma-
terials, of which the natural production is a peculiar attribute of the
tissues of the skin.
Among the parts in which these skin-bearing cysts may be found an
some that have no natural connexion with the skin.
1. They are frequent in the ovaries ; one or more Graafian vesides
enlarge and grow, and then, apparently, produce on their inner smfaee
a growth of skin, with its layer of cutis, subcutaneous fat, epidenniii
and all the minute appended organs of the proper hairy integument of
the body. The general likeness of the interior of these cysts to ordimuy
skin had been often noticed ; but the first minute demonstration of it
was by Kohlrausch,t whose observations have been fully confirmed by
others as well as by myself. Among the specimens in the College Mu-
seum, one (No. 164 a) presents all the textures of a hairy piece of skui
growing on the interior of one of the cavities of a large multilocular
ovarian cyst. Of the other divisions of the same cyst, some contained
* Museum of St Bartholomew's, Ser. xxzii. 39. Rokitansky gives to cases of this kind
thQ, name of cysto^arcinoma, and draws a just parallel between them and the instaneet of
cy8to>8arcoma. (Pathol. Anat i. p. 390.) Cysto-sarcoma be regards, nearly following MOt-
ler herein, as a combination of sarcoma with cyst-formation. The cases included by him
and Miiller (On Cancer, p. 170) under the name, cannot be all inclosed in the groups which
I have brought near together. (1.) Some are cases in which simple cysts are found within
solid tumors : these are named Cysto-sarcoma simplex, and such as these will be mentkmed
or referred to as varieties of fatty, fibrous, fibro-plastic, and cartilaginous tumors, in all of
which the formation of cysts may ensue. (2.) The Cysto-sarcoma proliferum, if it be cor»
rectly described as constructed of cysts contained in a solid tumor, and containmg ytmngir
cyits in their interior, I have never seen. The case to which Mailer refers as exemplifying
it, and which is figured by Sir A. Cooper (Illustrations, p. 4 1, pi. iii.), was, I believe, au in-
stance of proliferous glandular cyst in the mammary gland. (3.) The Cysto-sarcoma phyl-
lodes is a proliferous glandular cyst of the breast, and is especially exemplified by the cases
in which the intra-cystic growths are firm, lobed, pedunculated, and clustered, and in which
many cysts are close-set in the breast. But in this disease there is, I think, no solid tumor
in which the cysts are set : they appear to be themselves the primary disease, the solid
growths within them being secondary formations ; and if this be true, they cannot properly
be grouped with the examples of Mailer's Cysto-sarcoma simplex.
t Mailer's Archiv, 1843, p. 3G5.
OUTAHBOnS CTSTS. 869
&tty matter and loose hair; others, various fluids; others, secondary
ind tertiary cysts : and this is commonly the case. Another specimen
m the College Museum (No. 2624) shows very well the origin of these
ikm-bearing cysts. It is an ovary, with a cyst, the small size of which,
IB well as the structure of its walls, and the mode in which they are con-
nected with the surrounding substance of the ovary, leaves no doubt that
it IB a simply enlarged Graafian vesicle. Yet it contains some hairs, and
i small mass of fat, resembling the subcutaneous fat, with its tough
fibro-cellular partitions.
2. Cutaneous proliferous cysts may form in the subcutaneous tissue.
They are, indeed, rare in this tissue in man, except in cases of congenital
growths. In the little cysts about the brow, or in or near the orbit, the
inner sur&ce is often perfectly cutaneous ; and Lebert'*' has detected in
Boeh cysts all the minute structures and organs of the skin. Most of
these cysts are first observed at or soon after birth. Some similar speci-
mens of cysts lined with skin are in the Museum of the College.f These
were taken from the subcutaneous tissue of a cowand of an ox ; and, in
some of them, the inner surface of the cyst could hardly be distinguished
from the outer hairy integument of the animal.
8. Besides these, the common seats of cutaneous cysts, perhaps any
part or organ may in rare instances present them ; for the records of
surgery and pathology would furnish abundant instances of aberrant
cjsts containing hair and fatty matter, such as we must class with these
in which the cutaneous structure and products are more perfect. The
most singular and frequent of these rarer examples are in the testicle,^
the Iung,§ the kidney,|| the bladder ;Tf and under the tongue,** and
within the skull or brain. Those in the brain are of chief interest. I
found oneft many years ago in an elderly man. While he was in St.
Bartholomew's Hospital with an ulcerated leg, he suddenly died ; and
the only probable cause of death appeared to be a mass of granular fatty
matter mixed with short stiff hairs, which lay in the tissue of the pia
mater under the cerebellum.
A yet more remarkable case is in the Museum of St. George's Hos-
pital, in Mr. Csesar Hawkins's collection. It exhibits a mass of fatty
matter, and a lock of dark hair 1} or 2 inches long, attached to the
inner surface of the dura mater at the torcular Herophili. This was
* Abhandlungen, p. 99, e. s. The structure is well shown in No. 158 in the College
Maaeum.
t Nos. 161, 163, &c.
^ See Goodsir, in Edinb. Monthly Journal, June, 1845.
$ KolUker, in the Zeitschril\ ftkr wissensch. Zoologie, B. ii. p. 281.
I Mu8. Coll. Surg. 1904.
% Mus. Coll. Surg. 202G.
** Scbah, Pseudopiasmen, p. 154; and Mus. St. Bartholomew's, Ser. xxxv. No. 25.
tt Mus. St. Bartholomew's, Ser. vi. 50.
24
870 8EBACE0TJ8 AKD EPIDERMAL CT8T8.
found in a child two and a half years old, in whom it appeared to bin
been congenital.
It is perhaps only during the vigor of the formatiye forces in the
fostal or earliest extra-uterine periods of life, that cysts thus higUy
organized and productive are ever formed. The 9ebaeeau$j qndermaly or
euticular cysts that grow in later life are imperfect, impotent imitatioBi
of these ; yet clearly are the same disease, and are, therefore, most
naturally classed with the proliferous cysts, needing only to be named
according to their contents. We cannot tell, in any advanced case of
such a cyst, whether the more complicate structures of the skin ef«r
existed; if they did, they have' degenerated before the cyst became d
distinct size ; yet the retained likeness is sometimes shown in the fact
that, when such cysts are laid open to the air, they do not granulate,
but assume for their internal surfaces the characters of the adjacent and
now continuous skin.*
Of these sebaceous or epidermal cysts it is interesting to notice the
frequent hereditary origin. Perhaps, in the majority of cases, the
bearers of these have known one or more members of th^ir &niily simi-
larly endowed. They are certainly more commonly hereditary than aie
any forms of cancer.
I have already referred to the double mode of origin' of the qiider-
mal cysts. Sir Astley Cooper first observed that some among them
could be emptied, by pressing their contents through a small aperture ia
the cutis over them, and hence concluded that they are all examples of
hair-follicles distended with their secretions, and overgrown : but pro-
bably this conclusion is true for only a minority of these cysts. Thej
are, I think, comparatively few in which an aperture can be found ;t the
greater part are closed on all sides alike, and must be regarded as oysto
new-formed.
The characters of these epidermal cysts may be extremely various, in
regard not only to their walls, but to their contents. Their walls may
be thin, delicate, and pliant ; or laminated, thick, and hard, with tough
fibrous tissue ; or they may be calcified ; and I believe a general role
may be connected with the differences in these, as in other cysts, namely,
that the thin-walled arc the most productive, grow most rapidly, and aie
the seats of most active change.
Among the contents of these cysts we may observe extreme varieties.
The chief alone need be referred to. And 1st, we find successive produc-
tions of epidermis, formed in layers on the inner walls of the cyst, and
thence successively shed, and pushed inwards towards its centre. A
* See Home, Hunter^s Works, vol. iii. p. 635, and a remarkable case by Mr. Green, in the
Medical Gazette, vol. ii. p. 346.
t Mr. South especiallj notices this in his edition of Chelius*i Surgery, vol. ii p. 698. See
also Walther, in Vogel's Pathol. Anat p. 224.
8IBA0B0U8 AVD BPIDBRMAL 0T8TS. 871
section of saoh oysts (which were particularly described by Sir Everard
Home from the Hunterian specimens) presents layers of white soft
epidennifl, like macerated epidermis of the heel or palm. The external
liyers are commonly quite regular, white and flaky ; but the internal are
more disorderly, aa if broken up and mingled with less organized pro-
ductions.
2dly. A peculiar appearance is given to contents like these, where,
among the layers of epidermal scales, abundant crystals of cholestearine
ire mingled. They hence derive an appearance like that of the masses
to which Miiller* has given the name of cholesteatoma, or laminated
&tty tumor ; and, indeed, the few well-marked examples of this disease
which I have been able to examine, as well as Muller's own account,
mike me think that what he named cholesteatoma is only a combination
of layers of epidermal scales with crystals of cholestearine.f
The appearance produced by such a combination is quite peculiar. It
fonns nodulai: masses of soft and brittle substance, like wax or sperma-
eeti, the surfaces of which present a bright glistening, like that of
motber-of-pearl, while their sections are finely laminated. It is a rare
&eiK; the most frequent seats of well-marked specimens appearipg to
lie in ovarian cysts, and in connexion with the membranes of the brain.
The ekaracters are well shown in the contents of a small ovarian cyst in
8t Bartholomew's Hospital ; and in the tumor within the occipital part
rf the cranium, in Mr. Hawkins's collection, to which I have already
wferred. Striking examples are figured by Cruveilhier ;X but the want
rf microscopic examination leaves their constitution uncertain.
Wly. In the opposite extreme to these cysts, in which the cuticular
product is most perfect, we find an innumerable variety of contents, of
hif- and ochre-yellow, and brownish materials, that seem to consist
Qiinly of degenerate cuticle mingled with sebaceous secretions. The
microscope finds in them a confused mass of withered scales, of granular
and fatty matter, clustered and floating free, of cholestearine-crystals, and
of earthy matter in free molecules, or enclosed within the cells or scales.
And all these may be floating in a turbid liquid, or retained in some
soft tenacious mass, or clustered in hard nodular and pointed masses,
projecting like stalactites from the old cyst-walls.§
One more phase of this disease deserves especial notice — that in which
the cyst ulcerates, and its contents protrude. An inflammation in or
about the sac often appears the inducement to this change ; and some-
times the inflammation itself can be traced to nothing but disturbance
of the general health. The probability that it may thus arise makes
* On Cancer, p. 155.
t See, also, an account of such a case by Mr. W. Adams, in Proc. of Pathol. Soc. 1850-1.
Otlier writers since MoUer have applied the name of cholesteatoma more vaguely.
X Anatomie Pathol, liv. ii. p. 6.
S College Museum, 157 a and 22C7. A most remarkable specimen is in the Museum of
Guy*i Hospital, wbiob was removed from an old roan's thigh.
i
872 8EBA0E0US AND EPIDERMAL CTSTS.
the caution very valuable which Mr. Humphry* gives concerning the
removal of all tumors. " It is always well," he says, " to bear in mind that
persons are most likely to consult us respecting these, or other growtb
of the like kind, when they are out of health, and consequently unfit to
bear an operation ; they do so because the tumor Ls then most productive
of pain and annoyance."
A distressing instance of the truth of this occurred to myself fire
years ago. A strong but very intemperate man came to me as an
out-patient with an ulcerated sebaceous cyst, about three-quarters of an
inch in diameter, just below and to the right of the umbilicus. He had
observed a tumor here for sixteen years ; but he had scarcely thought
of it till, during the last five weeks, it had grown quick, and in the last
fortnight had ulcerated. I saw no reason to be very cautious in such
a case ; so slit the tumor and removed it, as well as the thickening and
adhesion of the parts would allow. In the evening, having returned
to his work and some intemperance, hemorrhage ensued from a small
cutaneous vessel, and before he reached the hospital he lost more than a
pint of blood. I tied the artery, and applied solution of alum to the
rest of the wound, for its whole surface was oozing blood, and he was
admitted into the hospital. The next day he became very feverish,
and he appeared as if he were going to have typhus, which was then
prevalent. But from this state he partially recovered; and then ab-
scesses formed in his groins, and discharged profusely. Nothing im-
proved his health, and three months after the operation he died, appa-
rently exhausted by the continued discharge from the abscesses, and
witli both external epigastric veins and parts of the femoral veins full of
old clotted blood — the consequence of slow phlebitis.
Cases like this, or ending fatally much sooner than this did, with ery-
sipelas or more acute phlebitis, have occurred to many surgeons. Thej
need no comment to make them instructive.
I believe the contents thus protruded from cutaneous cysts may* become
vascular. I have not seen this event, but it seemed certain in a case
observed by Mr. James Reid. A woman, eighty years old, had numerous
cysts in her scalp. They were like common sebaceous cysts, and three
of her daughters had cysts like them. Two years and a half before her
death, one of the cysts, which had not previously appeared different from
the rest, inflamed. It was opened, and sebaceous matter was discharged
from it. The opening did not heal, but ulcerated, and a small hard lump
remained under the ulcer for n year, when, after erysipelas of the head,
it began to grow, and rather quickly increased to a mass nearly five inches
in diameter, which occasionally bled largely. The mass has the appear-
ance of the firm contents of a cuticular and sebaceous cyst, and contains
• Lectures on Surgery, p. 130; from t!ie Provincial Medical and Surgical Journal.
I
I
I
BENTIGBBOUB CYSTS. 873
abondant epidermal cells ;'*' so that there can be scarcely a doubt that it
had its origin in the contents of such a cyst.
5. Concerning cysts containing teeth, a few words must suffice. They
are of two kinds. Some, occurring in the ovaries, and more rarely in
other parts, bear, with one or more teeth, the products of skin, as hair,
epidermis, Jccf These may be regarded as diseases of the same gene-
ral group with the cutaneous proliferous cysts ; and the great formative
power which they manifest is consistent with their occurring only in em-
hryonic or foetal life, and in the ovaries, in which, even independently
of impregnation, one discovers so many signs of great capacity of deve-
lopment.
Other dentigerous cysts occur within the jaws. In some cases, cysts
are hollowed out in the substance of the upper or lower jaw, and are
fined with a distinct membrane, to some part of which a tooth is attached.
I believe these are examples of tooth-capsules, from which the teeth,
though perfectly formed, at least in their crown, are not extruded, and
irhich therefore remain, becoming filled with fluid, and growing larger. J
h other cases, that which appears as a cyst is the antrum, distended
, with fluid, and having a tooth imbedded in some part of its wall, and
projecting into its cavity. § In the most remarkable case of the kind,
Professor Baum removed a tooth from each antriun of a woman thirty-
eight years old. The distension of the antra, with excessive thickening
of their lining membranes, and thinning of their osseous walls, and with
aocomulations of purulent fluid, had been in progress for thirty years,
and produced horrible deformity of the face. The operation was com-
pletely curative.
* MuMum of St Bartholomew's Hospital, series xxzv. No. 57. Probably the case was
limifaur which is related by Mr. Abernethy in his Essay on Tumors, p. 117. Such cases
hare peculiar interest in relation to the question of the possible origin of certain cpitlielial
eucers in these cysts. This will be referred to in Lecture XXXII.
f A Yery remarkable specimen is in the Museum of St Bartholomew's Hospital (Mal-
ibrmatioDS, A. 177). It was presented by Mr. Kingdon and is described by Mr. Gordon in
the Med.-Chir. Trans., vol. xiii. In the anterior mediastinum of a woman twenty-one years
old, a tumor, probably of congenital origin, contained portions of skin and fat, serous fluid,
and sebaceous matter, and two pieces of bone like parts of upper jaws, in which seven
weli-fbrmed teeth were imbedded. In an ovarian tumor more than 300 teeth were once
finind : in another case, a piece of bone, like part of an upper jaw, with 44 teeth. See
Lsng, in the essay cited below, p. 11.
^ Two such cases are in the Museum of St Bartholomew's, Series i. 119, 119 A. I saw
a third cured by Mr. Wormald by cutting away part of the cyst, and removing the tooth.
$ The principal cases are collected in two essays, for which I have to thank Professor
Bauin, namely, Lang, Ucber das Vorkommen Von Z&hncn im Sinus Maxillare ; Tbbingen,
1844; and Glasewald, De Tumore quodam utriusque Antri Highmori; Gryphis, 1844.
874 VATTY TUMOBS.
LECTURE XXIV.
FATTT AND FIBRO-OELLULAR TUMORS: PAINFUL SUBCUTANEOUS
TUMORS.
Among the solid tumors, the first that may be considered b the fattj
or adipose tumor, the Lipoma of some, the Steatoma of others; themoit
simple in its texture, the most like the natural parts, the least liable to
variations ; a morbid growth so well known, that I can scarcelj hope to
impart any interest to an account of it.
Among the growths commonly included as fatty tumors, we find ex*
amples of both the forms of morbid hypertrophies of which I spoke in
the first lecture. There are both continuous and discontinuous nuvUd
hypertrophies of fat ; both fatty outgrowths and fatty tumors, more pro*
perly so called.*
The Fatty Outgrowth \a thus described by Sir B. C. Brodie, in hk
well known lecture upon fatty tumors. He says, '^ there is no disdnet
boundary to it, and you cannot say where the natural adipose stmcture
ends, and the morbid growth begins These tumors feel like &t,
but they may be distinguished from the common fatty tumors by their
having no well-defined boundary, and by their being less soft and elastie.
Such deposits may take place in any part of the body ; but I have seen
them more frequently in the neck than anywhere else."t Doubtless the
case will be familiar to you by which Sir B. Brodie illustrates this accoimt
— the case of a footman, with an enormous double chin, and a great maai
of fat extending from ear to ear, who was cured by the liquor pctanm.
The case already cited from Schuh's essay (p. 821), was of the same kind.
I can add nothing to this account, except the mention of a singular
case of fatty growth connected with the heart of a sheep.| The lig^
ventricle is nearly filled with a lobulated mass of fat, distending it, and
pressing back the tricuspid valve. The left auricle and ventricle are
similarly nearly filled with fatty growths, and fat is accumulated on the
exterior of the heart, adding altogether about twenty-five ounces to its
weight. The textures of the heart itself appear healthy, though it is the
seat of all these fatty growths.
The discontinuous Fatty TumarSy of which alone I shall now speak,
present a tissue exactly or very nearly resembling the normal fatty or
adipose tissue of the animal in which they grow. Certain differences
may, indeed, be sometimes found between the fat of a tumor and that of
* M. Lebert (Abbandlungen, p. 112) distinguishes the fatty tumors according to their de-
grees of isolation, as Lipoma circumscriptum and L. diffusum. A diagram illustrating the
general differences of the two modes of growth is given in the twenty-fif>h lecture.
t Lectures on Pathology and Surgery, p. 275.
X Mus. Coll. Surg., 1529.
FATTT TUMOBS. 875
tbe part in i^luch it lies ; such as the larger size of the tumor's cells, its
leM or greater firmness at the same temperature, and the usual crystalliz-
iDg of the margarine ; but I believe there are no greater differences than
nay be found in the natural fat of different parts of the same person.
It would be superfluous to describe or delineate the minute characters
of this well-known tissue : it is only in its arrangement that the tumors
hare any peculiarity worth notice. It is, in all, composed essentially of
doatered oil-cells ; but these are, in some tumors, placed in a uniform
naas, smooth on its surface, and only obscurely partitioned ; in others,
arranged in oval or pyriform lobes, projecting on the surface, easily sepa-
rable by splitting their fibro-cellular partitions ; and in some of these it
may be dissected into thin layers, which are wrapped in each lobe, one
lithin the other, like the leaflets of a bud. Moreover, any of these forms,
whether "simple," or "lobed," or "involuted," maybe either deeply
imbedded in the tissues, or " pendulous."
Fatty tumors are, I believe, always invested with a capsule or cover-
ing of fibro-cellular tissue ; and of these capsules, since they exist with
most of the innocent tumors, I may speak now once for all. The cap-
nde, then, of such a tumor is usually a layer of fibro-cellular, areolar, or
connective tissue, well organized, dry, and containing bloodvessels pro-
portioned to the size of the tumor. It appears to be formed of the fibro-
eellalar tissue of the part in which the tumor grows, increased, and often
strengthened, in adaptation to the bulk and other conditions of what it
endoees. It grows with the tumor, invests it, and at once connects it
vith the adjacent tissues, and separates it from them ; just as, e, g.y simi-
lar fibro-ceUular tissue does each muscle in a limb. Its adhesion to both
the tumor and the parts around it is more intimate than that of its layers
or portions to one another ; so that when such a tumor is cut into, it
may be dislodged by splitting its capsule, and leaving some of it on the
tomor, and some in the cavity from which the tumor is extracted. This,
at least, can be easily done unless the tumor has been the seat of inflam-
mation, which may thicken the capsule and make all its parts adherent
to one another, and to the tissues on either side of it. As Schuh observes,
when a fatty tumor is just under the skin its capsule is usually more closely
connected with the skin in the interspaces between the lobes than in
any other part, so that the skin appears dimpled over it, especially if one
squeezes the tumor at its base, and presses it up to make the skin tense.
In the capsule, the bloodvessels that supply the tumor usually first
ramify. One principal artery, indeed, commonly passes straightway into
the tumor at its deepest part, but the rest branch in the capsule, espe-
cially in any thicker parts of it that lie in the spaces between projecting
lobes of the tumor. Hence, with the partitions of the tumor that are
derived from the capsule, the bloodvessels pass into its substance.
The capsules of these fatty tumors may vary somewhat in thickness
and toughness ; and so may the partitions that proceed from them into
J'his h^.^!^ ;. ./^.^ ..
876 FATTT TUM0B8.
the mass. They are usually very delicate ; but they are sometimes thiii
and strong, and give a density and toughness which approach to the dii>
racters of a fibrous tumor. To such examples of fatty tumors de\iating
from the common type, Mliller* has assigned the name of Lipoma mix-
tum ; and Vogel,t Gluge,t Rokitansky,§ and some others, call them
"Steatoma,** and "lardaccous tumor" (Speckgeschwul8t).||
Fatty tumors usually occur singly ; but there arc many exception* to
this rule. Two or three in the same person are not rarely seen, and &
hundred or more may exist. Sir B. G. Brodie mentions such cases ; and
I am acquainted with a gentleman, who has borne, for nearly twenty
years, firm tumors, feeling like fatty masses, in the subcutaneous tissue
of his trunk and all his limbs. They are usually stationary, but some-
times one grows a little, or one diminishes, or a new one appears. Lately,
I have seen a woman, 50 years old, in whom a large number of mmilar
tumors had been growing for about ten years in the subcutaneous tissue
of the ai*ms, thighs, and haunches. They were all small and firm, and
felt like tumors of mixed fatty and tough cellular tissue.
The most frequent scats of fatty tumors are the trunk, and the parts
of the neck and limbs that are nearest to it ; but they may occur in any
part where fat naturally exists, and they are npt limited even to these.T
It is, perhaps, impossible to say why they should affect one locality of fat
rather than another. Their rarity in the human mesentery and omentum,
and the fat about the internal organs, is remarkable. I have never seen
one in the recent state in any of these parts ; and I know only two w
three specimens in museums.** In the College Museum (No. 194) is t
bilobed mass of fat, enclosed in a thick capsule, and attached by a long
pedicle to the intestine of an ox. In the trunk and limbs, they appear
least frequent in the parts in which the natural fat, though abundant, is
subject to least variations in its quantity ; such as the palms and soles,
and the bones ; and they are rarely, if ever, formed in parts of or near
the trunk where very little fat naturally exists, as the eyelids and the
greater part of the scrotum. Fatty tumors have, indeed, been found in
• On Cancer, p. 153. t Pathologische Anatomie, p. 179.
^ Pathologische Anatomie. § Pathologische Anatomic, B. i. p. 283.
n Mailer also gives the name of Lipoma arborescens to the pendulous fatty processes with
synovial membrane that are clustered about chronic diseased joints. Sir B. C. Brodie (Lee-
tares, 1. c.) describes a form of fatty tumor, which I have not yet seen, in which the tumor is
covered with a double layer of membrane, like a serous sac.
IT Mailer (On Cancer, p. 153) describes one between the optic nerves and corpora albi-
cantia ; and Rokitansky (B. i. p. 282), including both the tumors and the outgrowths, refers
to examples of Lipoma in the submucous tissue of the stomach, intestines, and bronchi ; in
the subserous tissue of the pleura, peritoneum, dura mater, and cerebral ventricles ; and in
the lungs, liver, and kidneys.
** One, referred to in Lecture xxi., is in the Museum of St. George^s Hospital. Other cases
are related by Vogel (Path. Anat. tab. xxii. fig. 1) ; Gluge (1. c. Lief viii.); Lebert (Phjrs.
Pathol, ii. p. 105.) They are not rare in the corresponding parts of horses and other domes-
^ mammalia. (FOrstenburg : Die Fettgeschwaiste und ihrer Metamorphose ; Berlin, 1851.)
FATTY TUMORS. 877
ke Bcrotnm ;* and one very remarkable case is related by Mr. Lawrence
■d Sir B. C. Brodie : but, perhaps, such tumors have not begun to grow in
k» part in which they were at length found ; they may have grown or
kifted into it.
This shifting of fatty tumors is worth notice ; for the fact may be
Bed in the diagnosis of them when they occur in the groin or scrotum,
IT Other unusual place.
A patient was under Mr. Lloyd's care, in St. Bartholomew's Hospital,
rith a strange-looking pendulous fatty tumor in the perineum. It hung
fte a pocket-flask between his scrotum and thigh : but he was quite clear
that it was in hii groin ten years before, and that it had graduaUy
Aifted downwards. It was removed, and no pedicle or other trace of it
nmained in the groin.
I find, also, a case by Mr. Lyford,t in which a large fatty tumor began
to grow in the abdominal wall, midway between the spine of the ilium
ttd the pubes, and thence, as it increased, gradually moved downwards,
ind was excised from the upper and inner part of the tliigh. And thus,
k Mr. Lawrence's case, the tumor began to grow in thq spermatic cord,
nd thence had partly extended and partly shifted into the scrotum
Mind the testicle, where it was extremely difficult to decide its nature.
The fatty tumors usually lie in the subcutaneous tissue, extending in it
between the skin and the deeper fascia : but they may extend more deeply.
Mr. Wormald removed one, from which distinct lobes or prolongations
pmed between the fasciculi of the trapezius muscle, and, expanding
below them, were constricted by them. In the case of a great fatty
tanorl of the neck, removed by Mr. Listen, the operation was made
fcrmidable by the lobes of fat extending deeply to the trachea and oeso-
pbgDs. In rare cases, fatty tumors may be altogether deeply seated: I
band one resting on the lesser trochanter of the femur, growing up by
die side of the pectineus muscle, but not prominent externally. Vogel
Beutions the case of a woman who had several fatty tumors, one of
liuchwas so closely connected with the nasal bone and the nasal process
tf the superior maxillary bone, that it was necessary to remove these with
it Mr. Abemethy also refers to a fatty tumor removed by Mr. Cline,
which adhered to the capsule of the hip-joint. § In the Museum of
the Middlesex Hospital is a fatty tumor one and a half inches long,
^hieh was removed from beneath the tongue, where it looked like a
loola; and in the College Museum|| is one taken from the substance of
•fe tongue.
Such are some of the chief facts respecting the structure of this kind
^ tumors. Of their life, I need say little.
Their development is, probably, like that of the natural fat.
Glage meotiont one in the labium of a woman seventy years old. It waspyriform, and
^ti\ like a bernta (Pftth. Anat. Lief. vuL Tail i. fig. 1.)
t Mctl. GajL, iv 348. J Mus. Col. Surg., No. 190.
S See also fibnodie, 1. c. ; Simon, Lectures on Pathology ; and others. | No. 1065.
878 FATTT TUMOBB.
Their growth is usually slow, and without pain or any affection of the
adjacent parts; but they often grow capriciously^ haying imeertun
periods of acceleration and arrest, of which no explanation can be giYen.
The extent of growth cannot well be measured ; for fatty tumors haTO
been cut out that weighed between fifty and sixty pounds, and such as
these, after twenty or even fifty years, were still growing, and might have
continued to do so as long as the patient lived. I believe the largest
in London is that in the Museiun of St. Thomas's Hospital, which was
removed from a man's abdomen by Sir Astley Cooper, and weighed 87
lbs. 10 oz.* One of the most formidable is that in the College Museum,
removed by Mr. Listen from a man's neck,f where it had been growing
for twenty-two years. A parallel to it is drawn in the splendid work of
AuvertJ
What degenerations the fatty tumors may be liable to are not known;
their diseases have some points of interest.
They may be partially indurated. The chief mass of a tumor may be
found with the characteristic softness, pliancy, and inelasticity of fat ; bat
in its substance one or more lumps, like hard knots, may be imbedded.
So far as I have seen, these depend on induration, contraction, and a pro-
portionate increase, of the fibro-cellular tissue of the fat; and the change
is probably due to slow inflammation of the tumor. It may be sometbnei
traced to frequent pressure. A laundress had a fatty tumor, as large at
a foetal head, above her ilium, and portions of it were as hard to the touch
as cartilage, and appeared to move so freely in the soft fat-tissue about
them, that one might have thought them loose bodies, or fluid within
cysts. Where these were, the patient had been in the habit of resting
her linen-basket.
The indurated parts of a fatty tumor may be the seats of bone-like
formations. This is, I believe, very rare ; and I have seen only the single
specimen in the Museum of St. Bartholomew's Hospital :§ but Auvert
describes the same change. ||
Cysts, also, may form in fatty tumors. In the case with partial indur
rations just mentioned, I found, in another part of the tumor, a cyst
with thin and partially calcified walls, which contained a glutinous and
greenish oily fluid. I presume it is to tumors of this kind that Gluge
gives the name of Lipoma colloides.
Suppuration and sloughing may occur in these tumors: but they are
on the whole very rare events, except in large pendulous tumors, which
have grown too large to be efiectively nourished through their bases of
attachment. Pathologically these changes have little interest; but in
practice they are more important, as being almost the only way in which
external fatty tumors arc likely to lead to death. Even in these cases,
• Medico-Chirurg. Trans, vol. xi. p. 440. t No. 190.
X Obs. Med.-Chir. Tab. li. See, for a list of the largest elsewhere recorded, Mr. Soothes
edition of Chelius's Surgery, ii. p. 691-2.
§ Ser. xxxv. 11. I TaK xtL
I
VIBBO-CELLULAB TUMOBS. 879
bweyer, they show no real imitation of malignant disease.'*' I once,
mdeed, saw a case in which the end of a pendulous fatty tumor in a
woman's perineum was so ulcerated that it looked like cancerous disease:
kt after a week's rest in bed, during which the patient menstruated,
h lost its malignant aspect. It now acquired (what the ulcers over and
m &ttj tumors commonly present) clean, inverted and oyerhanging,
wedge-shaped, granulating edges.
Lastly, respecting the causes of these tumors few things can be more
obscore. Nearly all knowledge on this point is negative. The growth
sty have followed an injury, and we may call this the cause of its for-
nttion ; but we can give no explanation why such an event as an injury,
whidi usually produces only a transitory impairment of nutrition, or a
triyial inflammation, should, in these cases, give rise to the production of
t new «id constantly growing mass of fat.
FIBBO-CELLULAR TUMOBS.
Under this name I propose to consider the tumors which, in their
minate* structure and their general aspect, resemble the fibro-cellular,
ireolar, or connective tissue of the body. So far as I know, no general
acoonnt of them is published. The first distinction of them was made, I
believe, by Mr. Lawrence,t who described an admirable example in his
paper on Tumors ; and they are briefly but accurately described by Mr.
Cssar Hawkins,! as a softer and more elastic form of the fibrous tumor.
Muller,§ also, refers to them by the name of Oellulo-fibrous tumor;
Vogelll by that of Connective-tissue tumor (Bindegewebgeschwulste),
comparing their tissue with that of the cutis ; and Rokitansky^ points to
them as a variety of '^ gelatinous sarcoma." But these passing references
Itave not obtained for this kind of tumor a general recognition, and in
many works it is altogether overiooked.
As in the laat kind, so in this, we find instances of both outgrowths
and tumors; t. e. of both continuous and discontinuous overgrowths.
The former are, indeed, abundant and often described ; for, among them,
as being formed chiefly of overgrowing fibro-cellular tissue, are the most
* On the possible coi^unction of fatty tumors and malignant disease, see Sir B. C. Brodie's
Lectures, p. 282 ; and the same on the combination of fatty and mammary glandular
tamon.
f Medico-Chirurg. Trans^ vol. zvii. p. 14.
^ Medical Gazette, vol. zxi. p. 925.
§ On Cancer, p. 14.
I Pathologiiche Anatomie, p. 185.
IT Path. Anat L p. 336. Mdller and others describe under the name of "* CoUonema'' a
tumor such as I have not seen, unless it be an example of very soA, fibroK;ellular tumor.
Rokitansky (i. 335) describes it as a very soft, tolerably clear, flickering substance, like gela-
tine, of grayish-yellow color. He briefly describes four specimens observed by himself.
Bruch describes as a genuine example of Collonema what I can scarcely doubt was a very
soft fibn>cellular tumor. (Ueber Carcinoma alveolarc j in Henle and Pfeufer's ZeitschriA,
1849, p. 356.)
■•I
t
880 VIBBO-CELLULAB POLTPI. *
frequent forms of polypi of mucous membranes, and of hypertrofihies if
skin or cutaneous outgrowths.
1. Nearly all the softer kinds of polypi, growing from mucous membiuM,
consist of rudimental or more nearly perfect fibro-cellular tissue, madeiv*
culent by serous or synovia-like fluid infiltrated in its meshes: the firas
kinds of polypi are formed of a tougher, more compact, dryer, and moit
fibrous or fascia-like tissue. Of the softer kind, the best examples aretk
common polypi of the nose : mucous, gelatinou.'t, or vesicular polypi, u
they have been called. These are pale, pellucid, or opa(|UC-whitish, pendi-
lous outgrowths of the mucous membrane of the nose, — most froquentljof
that which covers the middle of its outer wall. They are soft and eadj
crushed, and in their growth they adapt themselves to the shape of tk
nasal cavity, or, when of large size, project beyond it into the pharynx, or ^
more rarely, dilate it. As they increase in size, so, in general, doe» the
part by which they are continuous with the natural or slightly thickeDcJ
membrane become comparatively thinner, or flatter ; their surfaci-s miy
be simple and smooth, or lobed ; they often hang in clusters, and tbu
make up a great mass, though none of them singly may be lar^e. A
clear ropy fluid is diffused through the substance of such polypi, and the
quantity of this fluid, which is generally enough to make them soft uj
hyaline, appears to be increased when evaporation is hindered; form
damp weather the polypi are always larger. Bloodvessels enter ibrir
bases, and ramify with wide-extending branches through their substiDVf.
accompanying usually the larger and more opa»[ue bundles of filr-v
cellular tissue. Cysts full of synovia-like fluid sometimes exist witLic
them.
To the microscopic examination these polypi present delicate fibro-
cellular tissue, in fine undulating and interlacing bundles of filamonti.
In the interstitial li<[uid or half-liquid substance, nucleated cells appear,
imbedded in a clear or dimly-granular substance ; and these celL< miy
be spherical or elongated, or stellate ; imitating all the forms of such i?
occur in the natural embryonic fibro-cellular tissue: or, the mass mavl*
more completely formed of fibro-cellular tissue, in which, on adding acetic
acid, abundant nuclei ap[)ear. In general, the firmer the polypus is, the
more perfect, as well as the more abundant, is the fibro-cellular tissof-
The surface is covered with ciliary epithelium exactly similar to that
which invests the healthy nasal mucous membrane, and supplies the most
convenient specimens for the examination of active ciliary movement m
human tissues.
The soft polypi that grow, very rarely, in the antrum, and other cavi-
ties communicating with the nose, are, I believe, just like these.* And
those of the external auditory passage are, in structure not essentially
different. All that I have been able to examine appeared composed of
* See Schuh, Pieudoplasmen, p. 70 ; the bedt ac(*ouiit of i^olypi I have yri read.
CUTANEOUS OUTGROWTHS. 881
rndimental fibro-cellular* tissue : but they are generally more vascular,
firmer, and less succulent than the nasal mucous polypi ; they are also
much more prone to inflammation and to superficial ulceration, perhaps
through being so often connected with disease of the tympanum or its
membrane. The mucous polypi of the uterus, are also, I believe, like
those of the nose.
A large, deeply lobed, soft, and nearly clear polypus in the urinary
hladder, the only specimen I have seen in the recent state,t was com-
posed, in part, of very fine filamentous fibro-cellular tissue, and, in greater
part, of granular, or dim, homogeneous substance, with imbedded nuclei.
Over the substance which these formed, there was an immense quantity of
tessellated epithelium, with large scales, like those of the epithelium of the
month : indeed, so abundant was this, that it formed the chief constituent of
the smaller lobes of the polypus. Once, also, I have been able to examine a
polypus of the rectum, which, being soft and succulent, might have been
classed with these ; but it was composed almost entirely of gland-tcxturcs.
It was like a disorderly mass of such tubular glands, lined with cylindri-
form epithelium, as are found in the mucoits membrane of the rectum.
These were heaped together with some intersecting fibro-cellular tissue,
and with abundant viscid fluid like synovia or thin mucus. The polypus
was spheroidal, about two-thirds of an inch in diameter, and attached by
a pedicle nearly an inch long to the anterior wall of the rectum : it received
M abundant a supply of blood through the pedicle that I think excision
would have been very unsafe, unless I had first tied the base of the pedicle.
2. The best examples of Cutaneous Outgrowths of which, as I
have said, a second division of the fibro-cellular outgrowths is composed,
are those which occur in the scrotum, prepuce, labia, nymphje, clitoris
and its prepuce. J These, which reach their maximum of growth in the
huge '^ elephantiasis scroti" of tropical countries, consist mainly of over-
growing fibro-cellular tissue, which, mingled with elastic tissue, and with
more or loss fat, imitates in general structure the outer compact layer of
the cutis. Their tissue is always closely woven, very tough, and clastic;
in some cases it is compressible and succulent, as if anasarcous, and it
yields, on section, a large quantity of serous-looking fluid ; in others, it is
much denser, interlaced with strong, shining bands, like those of a fascia ;
in others, it is meshed with intervening lobes of fat ; and in others, it is
uniformly solid and glistening, yellowish, or with an ochre tinge, and like
ndder. The minute textures are, however, I believe, essentially the same
* M. Lebert says the specimens he has observed were composed of fibro-plastic* tissue.
Professor Baum tells me he has generally found the surfaces of aural as well as of nasal
polypi covered with ciliary epithelium.
t It is in the Museum of St. Bartholomew's, and is described by Mr. Savory in the Medi-
cal Timet, July 31, 1852.
1 1 suppose that the disease named Molluscum simplex should be classed with thefc;
•W I have never seen an instance of it. The best accounts that I have read are by G.
Simon; "Die Hautkrankheiten,'* p. 50 and 219, and Jacobovics; Du Molluscmn.
882 VXBBO-CBLLULAB TUMORS.
among these diversities of general aspect ; they are, in Tarioiia proportioi
the usual textures of the cutis and subcutaneous tissue, excepting (so i
at least as present obserration extends) the smooth muscular fibres. H
diversities of external form are more numerous. In some, as, most mti
monly, on the nymph» and prepuce of the clitoris, the maases are m
pended by comparatively narrow pedicles; thus, also, are suspcyi
most of the small cutaneous outgrowths that are common on the tnal
and limbs ; in some the bases are very broad, as in the nose, in wUdl
moreover, the growth of the skin is generally associated with acne m
dilatation of its minute bloodvessels ; in some, as in the elephaatka
scroti, a large extent of skin appears uniformly affected. Again, in M
fcrcnt instances, they are lobed, or less deeply subdivided, or smooik •
warty on their surfaces ; healthy or darkened epidermis covers thai
and the sebaceous glands and hair follicles sinking beneath their m
faces, as in the healthy skin, arc not unfrequently considerably enlaigri
In the elephantiasis, of the extremities and of the scrotum, not only ik
isolation, but even the circumscribed appearance, of a tumor is lost; ik
affection is classed with the diseases of the skin rather than with tasaoi
and, in morbid anatomy, is, perhaps, not to be distinguished fron ik
consequences of chronic or repeated inflammations of the integuaaii
In all cases, however, let the external form be what it may, there is md
uninterrupted continuity between the several tissues of the overgnmd
and those of the healthy cutb that the disease might be taken u ik
type of the "continuous overgrowtlis."*
Fibro-Cellular Tumorp, properly so-called, arc much rarer thiDlk
outgrowths of the same texture which I have just described. They m
also rare, in comparison with other tumors ; and this is sinpilar, €0i
sidering the abundance of the fibro-ccllulnr tissue naturally existing^ il
general diffusion, its easy formation after injuries, in disease, and era
in and about other tumors. I can in no wise explain the fact ; bn il
is certain that for ten tumors formed of fat or cartilage (tissues wbicl
are rarely produced in other diseases), we do not find more than m
formed of fibro-cellular tissue.
The form in which the fibro-cellular tumors are most frequently
is that of oval or round masses of soft, elastic, close and pliant ti
smooth and uniform, or, when they grow among yielding parts, dccpl
and variously lobed. Their exterior surface is connected with the wif
cent parts by a capsule of fibro-collular tissue, which generally spU
readily. When handled they feel peculiarly tense and elastic; the
* Wcll-marketl ^jieoimcni of cutaneous outgrowths are in tlie Muwum ot ihr CoUi|
Noa. T2H3 to 221NJ, '.MfiC? ; 27U8 to 2714 ; and in that of St. Barttiolomrw't. Ser. xi. IS. 1
Strr. xzviii. lb; and Ser. zzzii. 30, 37. I lately cut one from a man's nates (a very uimm
place of growth), which weighed upwards of eight {Kninds. It liad l>cen giDwing for iwa
years, and formed a great i>endulous mass, on which he used to sit: its basa ooTerad I
whole region of the glutei muscles.
VIBRO-OBLLULAB TUMORS.
888
mrfaee may shine like a thin sac fiill of fluid. On their sections
opaque white bands, intersecting a shining succulent basis-sub-
of Berona-yellow or greenish-yellow tint. Through this basis the
eonne in circles or wayy lines, or form complete partitions ; or,
m the smaller lobes of the tumor, they run without order, only forming
itite marks on the yellow ground-color, but giving no appearance of
or of regularly fibrous structure.
!nie peculiar yeUow color of the basis-substance of these tumors makes
look at first like fiftt ; it is due, however, not to fat, but to a serous,
pr iijiiOTiarlike, or very viscid fluid, which is infiltrated through the
of the tumor. The mass is just like anasarcous cellular tissue ;
of all like the subcutaneous cellular tissue of the back, as one sees
k dissected in a dropsical body. When such a tumor is cut through or
-rfhed, the dear yellow fluid oozes from it, or may be abundantly pressed
til; in alcohol the same fluid coagulates ; in both cases, the filamentous
IJMM contracting, becomes denser and more compact, and more uniformly
ipmiie white, like that of the softer varieties of fibrous tumor. It is to
Ihae last-named tumors, indeed, that the fibro-cellular have the nearest
Illations^ and into them that they '^ pass" through gradational specimens,
kft there is just the same difierence, as well as just the same relation
khreen these kinds of tumors, as there is between the natural fibro-cel-
hhr and fibrous tissues ; and there is a similar propriety in distinguish-
if them.
Examined with the microscope, the fibro-cellular tumors display the
fiamentous tissue or appearance characteristic of that after which they
m named. In many cases, or in many parts, parallel, soft, undulating
flunents are found
coDeeted in fasciculi,
lUeh interlace, and
fan which single
ilaiiients can often
k traced out (fig.
52); or, where this
ii not seen, the tez-
tve looks filament-
W» through mark-
iigi or wrinkles of
tk nirfiuse of a more
^Mttiogeneous sub-
•teKse. The best
^eloped and most
y^nneiatom tissue is in the intersecting white bands: but similar tissue
^ usually present everywhere. In many instances abundant nuclei
Fig. 62.»
^ Microfoqpic elements of a fibro-cellular tninor, with cells in various stages of elongation
^*^ sxmiuatioo into fliamentt. Bfagnifled about 450 times.
884
f IBBO-CELLDLAB TCIIOBS.
appear among the filnmcnte, or imbedded in the more liomo^cDrom m^
stance, and acetic acid rarely fails to bring into view snch naelci kt
crowds. In many, aW, cells like those of granulations, and o
elongated and attenuated, appear as if in process of dcrelopmnit aflft' '
filaments.
The homology of these tumors, in respect of tissue, is thus as perM '
as that of tlie fatty tumors. In chemical analysis they may yield i
tine from the well-formed fibro-cellular tissue ; but I beliere they ;
much more albuminoas a^
'^"* ter from their imperfccl^
dcTclopcd tiMue, and fna i
the serous fluid that is MaU
in them.
In general, there is Miilf
complete uniformity thrti^
the whole mass of one rf
these tumors. OftentiiiM.
however, different ponioa
are more or U-ss oMlnasUia
(if I may so call them); ani
wrbicb is more remarfcaUt.
portions of cartilage, mw-
xmv* partially ossified, nay
Ih- found in or over ihra-
I have thrice seen thi*. Ii
the first case iiodulos of cartilage were iinbediletl in a fibro-rcllnlar trnwr
that grew in tlio l)all of the grout toe : in the second (a ximilar tmnor
fiiiiii tile tbigli) (fig. ;V1), a jmrtioii of its surface, and one of itsthirf
parlttiunf, were fonno'I willi cartilage partially oscifie*!; in the thinli
similar tumor from the thigh was thinly, but completely, eneased ml
bimct Moriwcr, bcsidos the ilifikTcnces dependent on mixlnn* rf
other tiiisues wiih those proper to the tumors, some may be found wliifl
are due to parts (if the tuiiiiir being immature or imperfectly devi-lni*-!
ami from this imjH'rfcct state dcgetier.ite. I have lately seen two-/;
sjiecimt'iis, of wliich one was ri'iiioved from the inner and deeper {•v-
of a gontleiiian's hniii by Mr. Lawrence; and the "tber. seated boiw-
the supcrfu-ial ami ili-ep muscles of a woman's fnrearm. was removoilti-
Mr. (iay. The fonner was of three years', the latter of two yMi>.
growth. Both were of oval form, deeply lobeil. very soft, loosely e«-
nectinl by a thin capsule with the adjacent healthy parts, and aUat tifib'.
inches in chief diameter. Partitions, proceeding fnim the cupi-ale. »r.A
including large bloodvessels, intersected the tumors, which were maior
Iniia: mlucnl unc-lialf. DemTibvil sbovi-,
t All ilicw upcriniens aro hi tlic Mufcui
li cnnifniio niiil paniallj ei
ml p. 3l>'.'.
or St, Biinlioluincw'i IIo*]>i»l.
VIBBO-OBLLULAB TUM0B8. 885
posed of B bright aerons-yellowy flickering, but tenacious substance,
pdlocidy like siie-gelatine. Opaque- white lines traversing this sub-
uee gBY6 it the general appearance of the softest and most succulent
o-cellular tumors, or of the common mucous polypus of the nose.
Sieee characters, which were common to large portions of both tumors,
% however, in some lobes of each, widely deviated from. In the
wr from the ham, some k)be8 were suffused and traced over with
l^t crimson and vermilion tints, and looked like lumps of size and
nflioa ill-mixed for an injection. Other lobes had patches of buff-
ored or ochrey soft shreddy substance, or consisted almost wholly of
li a substance. In the tumor in the forearm there was less appear-
DB of vascularity, but the ochrey substance was more abundant, and
rts of some lob^ seemed liquefied in a turbid thick fluid of ochre or
f-yellow tint. In some portions it had a greenish-yellow hue, as if
Blnted with dried-up pus ; in others, it was nearly white and brain-
»; in others, it had mingled shades of pink and gray. But various
were the aspects of these tumors, so that with the naked eye it would
wt hem extremely difficult or impossible to discern their kind, yet, in
i puts, they showed microscopic structures characteristic of the fibro-
Ihilar tissue in an immature state. Serous or synovia-like fluid
isd from them, but none that was pulpy or cream-like. The serous-
lored parts consisted mainly of well-foriped fibro-cellular tissue, or of
okmr imperfectly fibrillated blastema, with closely imbedded corpuscles,
a nndeL Many of these corpuscles were clear, but many were
innlar, as if with fatty degeneration, or appeared changed into small
innle-masses. In the buff and ochre-colored parts, similar tissue or
irtema was sprinkled over, or was quite obscured, with minute shining
ick-edged molecules, like oil-particles, and with drops of oil. In other
rta, some nuclei appeared like those of very soft cartilage ; in others,
fstals of cholcstearine were mingled with the oily matter. In the
eeniah yellow parts, also, were corpuscles, like shrivelled pus-cells,
zed with fatty particles and debris; and again, in other parts, cells
iDgated like those of granulations.
No specimens could illustrate better than such as these the necessity
' learning, as I have already said, to distinguish, in each tumor, the
oeeeding varieties presented in the phases of development of prema-
m degeneration and of disease.
The most frequent seats of fibro-cellular tumors appear to be the scro-
Qi, the labium or the tissues by the side of the vagina, and the deep-
iited intermuscular spaces in the thigh and arm. They may occur,
X>bably, in many other parts ; but either they particularly affect these,
' else a singular chance has shown them to me in these situations with
mal frequency.
In the scrotum I have been able to examine two cases, and have found
26
386 FIBRO-CBLLULAB TUMOBS.
records or notices of many more. The first case is represented in a kq
specimen in the Mnseum of St. Bartholomew's, and in a drawing mti
shortly after the parts were removed. The patient was a carpenter I
years old ; and, when he was under Mr. Stanley's care, the tnmor U
e)dsted four years. It was a huge mass, about a foot long, and u i
seven inches wide, filling the scrotum, and drawing over it all the i^
cent integuments. A collection of fluid, like a hydrocele, was at il
lower part, a large hernial sac was above it, and the scrotum was iUi
and oedematous. The obscurities these complications threw upon Ih
diagnosis of the tumor, the doubt how far the hernial sac might eito^
the patient's age, and his aversion from any operation, were sufficMOlli
dissuade from active interference.
The patient died about half a year after leaving the hospitaL Tk
tumor had attained the weight of twenty-four pounds ; the testicle, iM
a distended tunica vaginalis, lay prcssed-down below it, and the hcnU
sac was quite clear of it above. It was easily separable from the iv
rounding tissues, into which many lobes extended far from the cW
mass, and on section appeared partitioned into lobes of various bims ad
shapes. It had all the characters which I have described as bdoag^i
generally to these tumors, varied only by the unequal collectioiii fj
blood or of serum, or by its various firmness of texture in its sennl
portions.
A similar case was brought to St. Bartholomew's by Mr. C. R. Thatf
son, to whom I am indebted for the history. The patient was a pariik
clerk, 70 years old, a sickly-looking man, and the tumor had been ni
years in progress before his death. It was first noticed as a hardatf
just above the testicle ; but, as it constantly increased in size, it fiU
the whole scrotum, displacing the adjacent integuments, and looking H
first sight like an enormous hydrocele. Its surface was uneven and loM
in some parts feeling hard and brawny, in some soft and fluctoati^
For many years it was inconvenient only by its size and weight ; M;
about a month before death, one of its prominent parts sloughed, tfi
hemorrhage took place from it. After this, more extensive sloagliB|
took place, and more considerable hemorrhage, and the patient sanL
The tumor had the same characters as the last, except in the part tkH
was sloughing, which was denser and more compact, and of dark, bknA
stained color, like congested liver. This might have been thought Oft
cerous ; but with the microscope I found only fibro-cellular tissue iafl
trated with inflammatory exudation and blood ; in other portions, unmiztf
fibro-cellular tissue.*
To these cases I might add one related by M. Lesauvage8,t in whifl
* The two foregoing cases are published by Mr. Thompson in the Medical Gaiecie, Mi
30, 1851.
t Archives G^n. de M4d. t. iz. p. 212, 1845. M. LesauTages refers to aDocher veiy pi
bable case in which Bajie removed the tumor. Ii was of three or four jreari* growth, ai
as large as a head. The patient died, without return of the disease, seren or eight yea
•Aerwards.
VIBRO-CELLULAB TUMORS. 887
tte tumor, in a man 70 yean old, weighed at least 44 pomids, and was of
ndi siie that, as the patient sat with it resting on his thighs, it reached
to his sternum and beyond his knees. And another of the same kind is
rdated by Dr. OTerrall, which he removed successfully ; but, excellent
IB the surgery of this case-was, its pathological completeness is marred
ky the suspicion that a small portion of it was of •cancerous structure,
tnd by the finding of a *^ solitary, hard, circumscribed tuber" in the
patient's liyer, when, some mondis after complete recoyery from the
iteration, he died with phthisis."*"
Of the similar tumors growing by the vagina, the best instance that I
how is that recorded by Mr. Lawrence.f A portion of the tumor is in
the Museum of St. Bartholomew's Hospital ; and, though altered from
its first condition, it proves the identity of the disease with that of which
I have been speaking.
The patient was a lady, 28 years old, and the tumor, suspended from
die labium and buttock as far as the coccyx, reached near to her knees,
IBS as broad as her two thighs, and measured 82 inches in its greatest
drcnmference. It had been growing four years, and produced no incon-
Tenience except by its weight and bulk. It was soft and lobed, and the
skin was loosely connected with it. Mr. Lawrence removed the greater
part of this tumor ; but a portion which advanced into the labium and
along the side of the vagina could not be eradicated : this was therefore
CQt across ; and, when it had grown again, was removed in a second
operation two years afterwards. The patient then recovered perfectly,
and is still living, without any return of the disease, more than twenty
years after the operation. Mr. Lawrence's account of the tumor, and
its present appearance, leave no doubt that it was of this fibro-cellular
kind.
A similar specimen, weighing more than 10 pounds, was removed by
Mr. Liston from a patient 30 years old, in whom it had been growing
many years, and a portion of it is in the Museum of the College (No.
2715). Many of smaller size have been removed from the same part ;|
* I am indebted for these particulars, beyond what were published in the Dublin Journal
of Medical and Chemical Science, vol. i. 184G, to the kindness of Dr. OTerrall. Mr. Curling
(On Diaeaflet of the Testis, p. 51) refers to two cases of small " fibrous" tumors removed
ihxn the scrotum, in one of which the tumor was supposed to be a third testicle. These
were probably of the kind here described. So, probably, were those referred to by Schuh
(Pieadoplasmen, p. 69), in one of which a fatty tumor was combined with one of several
** fibroid" tumors in a scrotum.
t MediooX^iirurgical Transactions, vol. xvii. p. 11.
^ Mr. Lawrence, 1. c, refers to one by Mr. Earle. Cases are also described by Sir B. C.
Brodie, M6d. Gaz., vol. i. p. 484 *, Mr. Copsar Hawkins, Med. Graz., vol. xxL p. 925; Mr. Curl-
ii^ Proceedings of the Pathological Society, Part ii. p. 301 ; and (probably) by Dr. OTerrall,
Dablin Jounial, vol. i p. 520, and voL iv. p. 337. A specimen from a case by Mr. Keate is
in the Mnseum of St George's Hospital
888 riBBO-OELLULAB TUM0B8.
and I have met mth two wliich have presented the same
another phase.
A -womany 84 years old, had a tumor pendulous from the right wall €i
the vagina and the right nympha. It was a large flask-«haped mam,
about five inches in diameter, attached by a pedicle about one inch asd
a half in length and thickness, over the upper part of which the orifice
of the urethra was arched. All the lower part of the tumor was slough-
ing, and discharging an offensive ichorous fluid. The upper half was
covered with healthy mucous membrane, and felt uniformly tough,
pliant, and elastic.
The patient had noticed this disease for three or four years. It began
as a tumor, projecting into the vagina from beneath its right wall, and
in this situation acquired a large size before it protruded externally. It
was punctured, and then grew more rapidly ; but the protmaion did not
take place till about ten days before I saw the patient. After this pro>
trusicm it enlarged very quickly, and, with the sloughing, the general
health suffiered severely. I removed the tumor eighteen months ago^
dissecting it out with little difficulty, and the patient, I believe, remains
well.
It presented a well-marked instance of a very oedematous and sloughing
fibro-cellular tumor, and microscopic examination found abundant infiam-
matoiy exudation mingled with the rudimental fibro-cellular tissue.
At nearly the same time I saw a case essentially mmilar to this ; but
the tumor was suspended from the labium, and the patient was about 60
years old. And this last fact is, perhaps, worth notice ; inasmuch as,
with this exception, all the cases of the fibro-cellular tumor by the vagint
that I have met with have occurred in young women, while all the similar
tumors in the scrotum have been in old men.
The occurrence of such tumors as these in the scrotum and labium maj
make it necessary that I should particularly say they are not the same
disease as are the cutaneous growths which form the pendulous tumors*
the elephantiasis, as it is sometimes called — of the same parts, and which
I have already briefly described. The main differences are : — 1st. That
these fibro-cellular tmnors may be separated or enucleated from the
tissues among which they lie ; whereas the cutaneous growths have no
definite boundary, but are continuous with the proper tissue of the sero-
tum, or labium, or nympha ; the two diseases have the common diffe-
rences between tumors and outgrowths. 2d. In the growth of the fibro-
cellular tumors, the surrounding parts, including the skin, or the mucous
membrane, grow in adaptation to the tumor, but often defectively, or, at
the most, only normally ; but in the cutaneous outgrowths all the tissues
take part, and the proper tissue and appended organs of the cutis are
nearly as much exaggerated as the fibro-cellular substance. And 8dly.
In the tumors, fibro-cellular tissue is the highest form attained, or, at
most, a small quantity of elastic tissue is mingled with it ; but, in the
VXBBO-CELLULAB TUMORS. 889
potgTOWthSy all the comp<»ient stractnres of the akin and subcutaneous
tissue are increased.
The two diseases are thus different. Still, the fact is significant, that
the parts most liable to the cutaneous outgrowths are also those in or
Bear which the fibro-cellular tumors most frequently occur ; and it may
be noted that, among those parts in which fatty tumors are most rare,
the fibro-cellnlar are the most common.
For examples of fibro-cellular tumors removed from deep intermuscu-
lar spaces, I may refer to two specimens already described, and to two
others in the Museum of St. Bartholomew's Hospital One of these
m remoTcd twelve years ago, by Mr. Stanley, from an elderly man : it
ky under the vastus intemus muscle, and was easily dislodged from the
dvity in which it was imbedded : it was a smooth, spheroidal mass, thinly
mcapsuled, and the bright yellowish color of its surface made it to be
legwded as a firm-textured fatty tumor ; but the microscope found little
orno fat in it, and its present aspect leaves no doubt of its nature. The
pttient died after the operation, and had no similar disease in other
puts.
The second of these specimens was removed by Mr. Savory from be-
neath the tensor vaginae femoris of a man 38 years old. It was of un-
certain date, but had been observed about five months: it was firm,
elastic, smooth, movable, and painless. In the operation it was easily
removed from its resting-place on the rectus muscle and the inferior
spine of the ilium ; the patient recovered perfectly, and has remained
well for nearly two years.
This tumor was a smooth oval mass, measuring about 5 inches by 3|.
Both in general aspect and in microscopic characters it might have been
taken for a type of the species, except for the peculiarity of its being at
one end capped with a layer of cartilage and cancellous bone, and having
nodules of cartilage set along the course of one of the chief partitions
between its lobes (fig. 58).
To these specimens I may add another, in the College Museum, of
which Mr. Hunter has left the record that it was taken from the thigh,
and had been supposed to be an aneurism.
These seem to be the most common seats of the fibro-cellular tumors
but I have preserved specimens from other parts. One was removed by
Mr. Stanley from the sole of the foot, where, surely, we might have ex-
pected a fatty, rather than any other tumor. The patient was a healthy
man, 41 years old, and the deeply-bilobcd and very prominent tumor lay
in the subcutaneous tissue over the metatarsal bones, with small lobular
prolongations extending among the deeper-seated tissues. It was of
eight years' growth, and nodules of cartilage were imbedded in the pliant
and cedematous fibro-cellular tissue of many of its lobules.
890 FIBBO-OBLLULAR TUM0B8.
Another of these specimens was removed hy Mr. John Lawrence, with
the testicle, within the tmiica albuginea of which it appears to be entirely
enclosed. The patient was a healthy-looking man, 87 years old, and tiM
tumor had, in seven years, grown to a measurement of nearly six inches
by four. When first removed, it was to the eye exactly like a fat^
tumor, but it contained no fat, and was a typical specimen of fibro-ceUn-
lar tumor in a very oedematous or anasarcous state.
A third was removed from over the upper part of a girl's saphena vein,
by Mr. Skey. It was completely encased in bone ; but its mass was
perfect soft and elastic fibro-cellular tissue.
A fourth specimen is a tumor which I removed from the orbit of a man
40 years old, in whom it had been growing for about eighteen months.
It has the general and microscopic characters of the species, but is very
soft, and is composed of a cluster of small masses, looking almost like i
bunch of small gelatinous polypi of the nose."*"
A fifth is an oval bilobed tumor, about half an inch in diameter, whidi
I removed from a young man's tongue, in the very substance of whicb,
near its apex, it had been growing for three years. It was firmer thin
most of the others ; yet succulent, and formed an obscurely filamentou
tissue, abundantly nucleated.
The specimens to which I have now referred will be sufficient, I think,
to justify the giving a distinct name to the kind of tumor of which thej
are examples. There may be found, indeed, many specimens that w31
connect these with fibrous tumors ; but, as I have already said, if we may,
among the natural tissues, distinguish the fibro-cellular from the fibrofos
or tendinous, so should we make a corresponding distinction of the tumon
that are respectively like them.
I need only add a few words respecting the general history of these
tumors. They have been found, I believe, only in or after the aduh
period of life, and in persons with apparently good general health. Their
causes are wholly unknown. Their development appears to be, in most
cases, like that of many examples of natural fibro-cellular tissue, through
nucleated blastema; but I have often found in them abundant cells
lengthening and attenuating themselves into fibres, as in the organising
of lymph or granulations. These may have been formed from exuded
lymph : yet I am more disposed to think them proper rudimental parts
of the growth ; for they are peculiarly well marked, and have no appear-
ance of being produced in disease.
* Three cases of tumor in the orbit, which, I think, must have been like this, are described
by Schuh (p. 03) under the names *^ Zellgewebssch wamm," *^ Fungus C^llulosut.'* Besides
the specimens above described, which are all in the Museum of St Bartholomew's, I haw
seen two removed from the scalp, both of which, before removal, were supposed to be
cutaneous cysts. A tumor removed by Mr. Humphry (Lectures on Surgery, p. 187) from a
finger, and one described by Lebert (Phys. Pathol., p. 173) as a fibrous tumor of the neek,
were probably of this kind.
PAIHFUL SUBOUTANBOUS TUM0B8. 891
The growth of these tumors is quick, in comparison with the average
rate (so far as we can roughly estimate it) of innocent tumors. They
often enlarge very quickly ; but this enlargement is probably not growth,
but swelling, through increase of the cedematous efifusion : (and this dif-
ference between growth and swelling may be usefully remembered in the
diagnosb of many tumors.) The growth is usually painless ; but about
the yagina is apt to be too rapid for the superjacent tissues. Its possible
extent is very great. I have mentioned one tumor of 44 pounds weight,
and another of 24 pounds, which was still growing.
Of the diseases of these tumors, nothing has been yet observed, except
the sloughing and suppuration that occurred in one of the cases I have
mentioned. As to their nature, all that has been said implies that they
an completely innocent ; and I have seen no sufficient reason to doubt
that they generally, or always, are so. Once, indeed, I think such a
tamer recurred after removal ; and once, in the testicle, a small growth
of medullary cancer existed near, but separate from, a large fibro-cellular
tuQor: but these are the only suspicious cases I have known.
PAINFUL SUBCUTANEOUS TUMORS.
A group of tumors peculiar for the pain with which they are con-
nected, are thus named, and are so remarkable as to justify giving a de-
smption of them separate from that of the fibro-cellular and fibrous
tomors, with which, considering their other characters, the chief ex-
amples of them might be placed.
The painful subcutaneous tumor, or tubercle, has been often well
described in relation to its general characters. Its intense painfulness
was too striking to escape observation. It was described by A. Petit,
Cheselden, Camper, and others ; but the first, and to this time the best
general account of the disease, drawn from many instances, was given
fcy Mr. William Wood, in 1812.* Dupuytren added many instances to
those which he copied from Mr.. Wood's paper, and made the disease
much more widely known.f
The especial seat of growth of these little tumors is, as their name
implies, in the subcutaneous cellular and adipose tissue. They are most
frequent in the extremities, especially the lower : very rarely they occur
on the trunk, or the face.| They are about four times more frequent in
women than in men ; they rarely, if ever, begin to form before adult
life, or after the commencement of old age. It is seldom that local
injury, or any other cause, can be assigned for their occurrence. The
tomor usually lies just beneath the skin, scarcely prominent; it has a
capsule loosely connected with all the surrounding parts, unless it be to
* Edinburgh Med. and Surg. Journal, viii. 1812. Mr. Wood first gave these tumors the
■ppiopriata name which they have since borne.
t Lemons Orales, i. 530. He named them fibro-cellular encysted tumors.
X One ii mentioned by Mr. Ctesar Hawkins, as removed from the cheek by Sir B. C. Brodie
(Medical Gazette, voL zxi. p. 02C); and one by Dupuytren.
892 PAINFUL SUBOUTANSOUS TUMOBB.
the cutis, to which it may be tightly fixed, and which, in anch cases, is
generally thin, tense, polished, and like a superficial scar. Sometimei
the small bloodvessels of the skin over and around the tumor are en-
larged and tortuous, like those near a cutaneous nieyus ; but, else, tD
the adjacent parts appear healthy.
Tumors of this kind rarely exceed half an inch in diameter ; they are
usually spheroidal, oval, or cylindriform ; they are firm, nearly hard,
tense, and very elastic. Their outer surface is usually smooth, bright^
yellowish, or grayish, or pure white ; and their sections have the same
aspect and consistence, or are varied by an obscure appearance of pure
white fibres traversing a grayish basis.*
Among the painful subcutaneous tumors that I have been able to
examine microscopically, one was composed of dense fibrous tissue, witk
filaments laid inseparably close in their fasciculi, and compactly intw-
woven. These appeared to have been formed in or from a nudeatci
blastema ; for thick-set, oval, and elongated nuclei were displayed wfaci
acetic acid was added. Another was composed of well-formed fibro-eel-
lular tissue, with bundles of parallel undulating filaments, matted or
closely interwoven. With these were elongated fibro-cells, the products,
perhaps, of inflammation, to which the tumor appeared to have beai
subject. The substance between the filaments, and that from which they
were probably developed, was here, also, a nucleated blastema. A third
specimen presented obscure appearances of a filamentous structure, bst
no separable filaments ; it seemed composed wholly of such nucleated
blastema as was exposed by the action of acetic acid on the former speci-
mens. In some parts, also, this presented appearances of filaments and
nuclei arranged in concentric circles around small cavities, f A fourth,
which had existed for many years at the end of a woman's thumb, con-
sisted of large clear nuclei in a dimly-shaded homogeneous substance.
From these examples, or, at least, from the first three, we may believe
that the painful subcutaneous tumors may be formed of either fibro-cel-
lular or fibrous tissue, in either a rudimental or a perfect state. They
may also, I believe, be fibro-cartilaginous, as described by Professor
Miller,! and by many other writers. But whatever such slight diversity
of tissue they may present, the characteristic of all these tumors is their
pain ; pain which may precede all notice of the tumor, or may not com-
mence till much later, or may be cotemporary with it, but which, whea
* Sometimes the tumor has a central cavity filled with fluid, as in two cases by Mr.
Caruthers, in Edin. Med. and Surg. Journ., vol. xxxiii. ; but it is obser^iible that in one of
these, occurring in a man, a visible nerve was connected with the tumor. Perhaps tfaii
was a neuroma ; for in tliese the cystic character is not unfrequent.
t Like those drawn from a fibrous tumor of the uterus by Prof Bennet (On CaDceioas
and Cancroid Growths, p. 189).
J Principles of Surgery, p. 030. An engraving, from the sketch by Prof. Bonnet, makes
this the only sure instance of fibrocartilaginous structure. In the other recorded cases the
microscope was not used ; and the naked eye cannot discern between fibrous cartilage and
dense fibrous tissue.
PAIHFUL S17B017TANSOUS TUMOBB. 898
Oboe it has set in, may rise to very agony, such aa I suppose is not
•qnalled by any other morbid growth. It is not often constant ; but, gene-
imQy, without evident cause, or with only a slight touch of the tumor, a
paroxysm of pain begins, and, gradually increasing, soon reaches -a
terriUe sererity. Beginning at or near the tumor, it gradually extends
into all the adjacent parts, often flashing, like electric shocks, from one
part of the limb to another, or to the whole trunk. Such a paroxysm
my continue for a few minutes, or for several hours ; then it gradually
nbeides, leaving the parts sore and tender. While it lasts, the tumor,
whatever may be its condition at other times, is always exquisitely sen-
sitive : the muscles of the limb may act with irregular spasms ; or general
omvnlsions, like those of an epileptic seizure, may ensue ; or, the patient
&Us as if sunk by the intolerable pain, and faints. Sometimes, too, the
tanior itself swells, the bloodvessels around it become larger and more
tnrtuous, and the skin becomes cedematous or congested, imitating the
change which sometimes ensues in a neuralgic part. There arc many
dirersities in the characters and modes of the pain ; but this belongs to
all the instances of it, — ^that its intensity is altogether disproportionate
to its apparent cause, and that it cannot be explained by anything that
eta be seen in the structure or relations of the tumor.
This pain suggests interesting questions in relation to the pathology
^ all tumors ; but, before considering it, let me add some facts to com-
plete the history of these. They appear usually to be of very slow
growth. One, which I removed from the end of a thumb, had existed
fbarteen years, and was less than a quarter of an inch in diameter.
Another, which I removed from the leg of an elderly woman, had gradu-
tUy mcreased, for ten years ; yet, at last it was less than a half an inch
in diameter. In other cases they may more quickly attain the same
rixe; but this seems their limit; and, for any number of years, they
Bay remain sources of intense pain, and yet undergo no apparent change
of siie or structure. They are usually single. I have found only one
ctse in which more than one existed : in this case three lay close together
o?er the great gluteal muscle.* When excised, they are not apt to
mnr. I removed one from the back of the leg of a lady 28 years old,
from whom, two years previously, a similar growth was excised from
the same part. After the first operation the pain was scarcely changed;
ifter the second it ceased, and never returned. Sir Astley Gooperf
removed two painful tumors, at an interval of a year, from a young
lsdy*8 leg; but these are the only instances of apparent recurrence
that I have found. I believe that they have no tendency to ulcerate, or
to tssome any of the peculiar characters of malignant disease.^
* W. Wood, 1. c.
t lUoitr. of Disease of the Breast, p. 84.
t Dr. Warren (On Tumors, p. GO) speaks of a malignant form of the disease in which the
lymphatics are affected, but relates no case of it. The case requiring ampntation, which he
lelates, appears to have owed its severity to the treatment. Dupuytren (Le9ons Orales,
894 PAINFUL 8UB0UTANS0U8 TU110B8.
In considering, now, the painfnlness of these tumors, the first questkA
is their relation to nerves : are nerves involved in them ! and do they, m
Yelpeau* seems to hold, differ from neuromata, t. e. from the fibrooB or
fibro-cellular tumors within the sheaths of the nerves, only in their
position? are they only tumors within the superficial or sabcutaneoiB
nerves ?
The general opinion is against this supposition. Dupuytren says thit
he dissected several of these tumors with minute care, and never aawerei
the smallest nervous filaments adhering to their surface. I have BOOfjiA
them with as little success with the microscope. Of course, I may have
overlooked nerve-fibres that really existed. It is very hard to prove a
negative in such cases ; and cases of genuine neuroma, t . e» of a fibrov
tumor within the sheath of a nerve, do sometimes occur which ezadfy
imitate the cases of painful subcutaneous tumor. Such a case was under
Mr. Stanley's care two years ago. An elderly gentleman had for tm
years observed a small subcutaneous tumor over the lower part of
the semi-membranosus muscle. It was easily movable, and, till witbia
the last three months, had not been inconvenient; but at this tine
it became the seat and source of pain exactly like that of a painful sub-
cutaneous tumor. It was removed ; and I was able to trace, with tk
microscope, an exceedingly slender nerve, the filaments of which wen
spread out over one part of the tumor. The tumor was within the nemi-
lemma, and was uniformly firm, elastic, yellowish, and composed of well-
formed fibrous tissue.
Many that have been called painful subcutaneous tumors may hats
been such neuromata as this was. Still, I am disposed to think that
most of them are only so connected with nerves as ordinary innocent
tumors are, that received a few nerve-fibres in their substance. For
(1) the connexion of the nerves with even very small neuromata is not so
difficult to demonstrate, but that it should have been found, if it had
existed, in some of the many painful tumors that have been examined.
(2) The neuromata often occur in large numbers in the same patioiit ;
the painful subcutaneous tumor is nearly always single. (3) The neuro-
mata usually grow constantly, and seem to have no limit of size ; even
when subcutaneous, they commonly exceed the size of the painful tumors,
which generally grow to a certain small size, and in it remain stationary.
(4) Neuromata are most frequent in the male, the painful subcutaneous
tumors in the female sex. An analysis of 26 cases of neuroma taken
promiscuously, showed that 19 had occurred in men, and 7 in women;
while in 28 cases of painful subcutaneous tumors 23 were in women, and
5 in men ; evidence which is almost conclusive for the different natures
of the two diseases.
i. 542) says they have or may acquire a scirrhous nature, and then end with cancpfous
so/lening ; but he refers to only one case justifying such expressions, and this case is impe^
fectly described.
* M^decine Op^ratoire, torn. iii. p. 101.
PAINFUL 8UB0UTAHB0US TUMORS. 895
However, even if it oonld be proved that these painful tomors are
within nerves, the question respecting the source of pain would not be
fUly answered. We cannot ascribe the pain to merely the altered
mechanical condition of the nerve-fibres ; for tumors that are evidently
within nerves are not always, nor even usually, painful. It is remarka-
ble that, in nearly all the cases in which large tumors have existed in the
trunks of nerves, there has been little or no pain. The facts collected
hj Mr. Smith* are clear on this point. Moreover, the subcutaneous
tomors themselves often remain long painless, and then become, without
any other apparent change, extremely painful ; and there are instances
of tumors exactly resembling them, except in that pain has never been
felt in them. I removed such an one from a lady's forehead. It was
about as large as a pea, had been two years growing in the subcutaneous
tisBQe, and had never given pain except once, when it was severely struck.
It had all the apparent characters of structure of the painful subcu-
taneous tumor. I repeat, therefore, that we cannot assign the pain in
these cases entirely to altered mechanical condition of nerve-fibres in or
near the tumor. We must admit, though it be a vague expression, that
the pain is of the nature of that morbid state of nerve-force which we
call neuraigie.
Of the exact nature of this neuralgic state, indeed we know nothing ;
but of its existence as a morbid state of nerve-force, or nervous action, we
are aware in many cases in which we can as yet trace no organic change,
and in many more in which the sensible organic change of the nerves is
inadequate to the explanation of the pain felt through them. In both these
setBof cases we assign the pain (speaking vaguely) to a functional, rather
than to an organic, disorder of the nerves ; to a disorder commencing in
the nerves of the part which is the focus of the pain, but transmitted
from them to others which, in the nervous centres, are connected with
theuL
With this view of the neuralgic nature of the pain in the subcutaneous
tmnoTS many of their characters and circumstances agree. The pain is
commonly paroxysmal, and sometimes regularly periodical ; it is diffuse,
or flashing, electric, and most intense ; it often excites reflex spasmodic
movements, or more severe and general convulsions ; though not pecu-
liarly frequent in persons of extreme sensibility, yetit is often aggravated
by mental emotions, and the other excitants of neuralgic pains ; it is
sometimes increased, or first felt, about the time of the cessation of the
menstrual discharge ; it sometimes remains at or about the seat of dis-
ease for a long time after the removal of the tumor ; it is sometimes
attended with what is regarded as reflex vascular fulness, but it precedes
^0 organic change.
The consideration of the probably neuralgic nature of the pain in and
about these tumors is of interest in relation to the pathology of many
* Treatise on Neuroma.
\
896 FIBROUS TUM0B8.
others. The pains of many other tumors are probably, in greater or ka i
measure, of the same nature.
The irritable tumor of the breast may be called a neuralgic tanti;
Sir Astley Cooper's plates show, indeed, that some which he thus calM
were like the painful subcutaneous tumors ; but the more frequent an^I
believe, mammary glandular tumors, imitating in their stmctore tin
mammary gland itself. I derive this belief from the general appearaafli
and description of several specimens, and from what I found in two cam
with the microscope. A woman, 45 years old, was under my care wSk
a small tumor lying deep in her breast, which felt hard and not moTaU%
except with the tissue around it. She had been aware of this tumor tm
a month, and during all the time it had been the source of intense '^dart-
ing and dragging" pain, which often extended from it through the dial
to the shoulders, and along the neck and arms. The pain was deserihei
as* so like that commonly assigned to cancer of the breast, that, jodgiig
from it, and from the age and other circumstances of the patient, oas
could not but fear she had cancer. The doubt rendered it proper te
make an exploratory incision at the commencement of the operatioa.
This was done, and the tumor, having no cancerous aspect, was akae
removed. It proved to be a perfect example of mammary glandakr
tumor, such as I shall more fully describe in a future lecture. Thus tk
case seemed to be one of mere neuralgia in a glandular tumor of tk
breast : and it may be added, that it was only a striking instance of at
ordinary fact ; for such tumors are often at times extremely punfuL
Similar instances might be found, I believe, in tumors of other stno-
tures ; but, without entering further on their history, I would suggest
that the account of all these painful tumors makes it probable that the
pain the patients feel is, in great measure, neuralgic or subjective ; that
it has the tumor, indeed, for an exciting cause; but that it owns, besidea,
some morbid condition inherent or cumulative in the nerves themsehras,
so that at times they respond, with a morbid exaggeration, to an habitiial
or slightly increased stimulus. And if this be true of the most painfol
tumors, it is probably true, in various measures, of many others.
LECTURE XXV.
FIBROUS TUMORS.
The name of ^'fibrous tumor'' appears the best, among the sixteen or
more, by which different writers have described the tumors whose chief
characteristic is their likeness to the natural fibrous or tendinous tissoe
of the body. This, at least, seems the best for a general designation ;
and to those among them which are constructed of more than one ele-
mentary tissue we may give such names as "fibro-muscular," "fibro-elas-
tic/' "fibro-cartilag^oua," &c.
TIBKOrS OTFiemOVTHS AKD POLYPI.
807
The most frequent and notorioiu ezamploa of the species are the fibrous
tnmora, or fibrous bodies, of the nt«niB ; the " hard, fleshy tubercle of the
■tnns," u it was described by Dr. Baillie. From theae, chiefly, the
gweral, thov^ not all the microscopic, characters of the species may be
dascribed.
Fint, however, the usual distinctioD most be drawn between the tumors
nd the outgrowths of the same stnicture. The uterus presents exam-
ples of both.
The FiBBOna Poltpi oF the ateras, more properly so-called, are con-
tinuous outgrowths of and firom the substance of the uterus; the mncoua
nembrane and the muscular and fibrous tissues of the uterus, growing,
m TBiiety of propordons, into its cavity and that of the vagina. The
fibrous tnmors are discontinuous growths of similar tissue in or near, not
nit, the Bobstance of the uterus.*
T\tt distinction is often difficult to make during life ; for the pendulous,
pdjpoid, and narrow-stemmed outgrowth may
be mutated, in all its external characters, by a
tnBor growing near the surface of the atems,
and projecting into its cavi^, with a gradually
flinning investment of its muscular and mucous
tisBnes. On dissection, however, or in such a
•eetion m the adjoining diagram (fig. 54) may
Kprtaent, the continuity of the polypus or out-
growth, A, and the dia continuity of the more
csnmonly occnrmg tumor, b, may generally
be discerned, even in specimens which, Ulce two
IB the Museum of St. Bartholomew's Hospital,
in, in external appearance, exactly alike (xxxii.
IS and 84).
ffimilar differences exist among what are
cUsMd together as fibrous tumors of bone or
pennteum : some, as wc shall see, are tumors ;
Bome are outgrowths, and the line of distinction
amnt be well drawn.
Fibronsoutgrowthsarealso, sometimes, found I
In the form of polypi suspended in the pharynx,
or in the chambers of the nose, or in some of
tbe cavities communicating with them. But I *
We not been able to examine any of these minutely in the recent state;
* The diilinctkin is cxprcued b; M. Cruveilbier (AnHtomie PHiboIogique) hy llie termB
•wip» flbreui implanUa," tncl " corps flbrem non implaril*9 ;" but tbe " corpi libreiix" of
Ag bn«n, which were dmcribed bjr him, and led to tha renowned discussion at (he Freoch
Aoadenir <^ Medicine, were, for the moM pan, mammary glandular tumors, and nearly
■olidiAcd prolileroui cym,
t Fig. 54, diagram-ceclknis of an uKrine ourgrowlh (a) and of an uterine lumor (b).
BUh are like polypi, but the fbtmer ii continuoua with Uie subttance of the menu ; the
898 FIBROUS TUMOBS.
and I have seen so few in any condition, that I cannot tell whether some^
or even many, of them are not separate fibrous tumors, projecting the
mucous membrane, and pendulous, as fatty tumors often are, when tluj
grow just beneath the cutis. Neither the description by Schuh, accunte
as it is in other points, nor any other that I remember, decides thk
The same uncertainty exists as to the relations of the extremely me
fibrous polypi of the oesophagus and larynx. The fibrous Btmcture of
all these growths is well-marked, but comparatively soft and elastic, nl
intermediate between the structures proper to the typical examples of
the fibro-coUular and the fibrous tumors.
The Fibrous Tumors, of which alone I shall now speak, appear to
have a natural tendency towards a spherical or oval shape, with a smooA
or superficially lobcd surface ; but from these marks they often devitti^
in adaptation to mutual pressure or the different resistances of Burnnmd-
ing parts. When, for example, a fibrous tumor is penduloua, its mon
dependent portion usually grows most, or is most swollen ; it tends fim
the spheroidal to the pyriform shape, but retains a smooth surface: wlm
one grows into a cavity, it is apt to assume the shape of that cavitf,
whatever it may be, or else to become deeply lobed. Such varietiei m
these are often seen in the fibrous tumors of the upper jaw, acoordiag
as they grow into the cavity of the mouth, or in other directions; lad
greater diversities occur among many specimens of the fibrous tumon of
the uterus.
The fibrous tumors growing in solid organs have usually a oomplell
fibro-cellular capsule ; and in the uterine waUs this is peculiarly dry and
loose, so that, when one cuts on the tumor, it almost of itself escapoi
from its cavity. So, too, are covered the fibrous tumors in the subcu-
taneous tissue and in the nerves, and those parts of the fibrous tomoit
and outgrowths from bones which are in contact with other tissues tlna
those from which they spring.
To the touch, the fibrous tumors are usually very firm, often extremely
so ; they may even be as hard and incompressible as hard cancers. If
they are soft, or '^ fleshy,'' or succulent, it is, I think, always through
oedema or inflammatory softness and infiltration of their substance ; for
such characters as these are rare, except in the case of the pendulous or
protruding tumors, or in those that are manifestly diseased. Moreover,
in all ordinary cases, the fibrous tumors are heavy, very elastic, and veiy
tense, so that their cut surfaces rise in convexities, like those of inter-
vertebral fibrous cartilages.
In the examination of sections, of which fig. 56 may represent an
ordinary example, the most usual characters that one sees are, that the
tumors present a grayish basis-substance, nearly homogeneous, and into^
sected with opaque, pure white bands and lines. They have a general
resemblance in their aspect to a section of fibrous cartilagCi such as that
FIBBOUS TUM0B8. 899
of the semilunar or the intervertebral cartilages. Many varieties, how-
Bfer, appear ; the basis-substance tending towards yellow, brown, or blue,
ind the white lines being variously arranged.
It would be tedious to describe minutely these various arrangements :
bt it suffice that there are three principal, but often mingled, plans.* In
lome tumors, the bundles of white fibres tend to construct concentric
droleB round one or many centres ; so that, in the section, we have a
figoe imitation of the aspect of one or more intervertebral fibro-cartilages,
the appearance of concentric curved fibres representing an arrangement
of layers successively enclosed, in the same involute manner as I described
in one of the varieties of fatty tumors (p. 375). These are generallyihe
hardest and least vascular of the fibrous tumors ; usually, too, they are
spherical.
In another variety of the tumors, the white bands course in variously
sweeping curves and undulations, the components of the larger bundles
diverging and interlacing.
In yet another variety, the fibres are less fasciculate, and appear as
if dosely matted in a nearly uniform white substance ; and, in the ex-
treme specimens of this form, which are most commonly found on or in
the jaw-bones, a fibrous structure is scarcely to be discerned with the naked
eye : they look nearly uniform, glistening, pale or white, and very firm ;
but the microscope proves their identity with the other varieties.
As on the exterior, so in sections, these tumors present various degrees
of lobular arrangement. Some are uniform and scarcely partitioned;
iriule others are formed in distiiict and easily separable pieces ; and be-
tween these are numerous intermediate forms.
As a general rule, the vascularity of a fibrous tumor is in an inverse
proportion to its singleness and toughness of construction ; for the blood-
Teesels, as in the natural fibrous structures, are distributed chiefly or
exclusively in the fibro-cellular tissue partitioning and investing the denser
nbstance. The tumors thus present various degrees of vascularity. —
Some, when the vessels of the uterus are fully injected, appear still quite
wbite; but some appear as highly colored with the injection as the uterus
itKlf.t
In microscopic examination, one finds, among the fibrous tumors, cer-
tain varieties of composition which are not always, if at all, expressed in
their more manifest characters. In all, I believe, a large portion of the
mass consists of tissue resembling the tendinous or fibrous ; being com-
posed of exceedingly slender, uniform, pellucid filaments, undulating or
crooked, more or less perfectly developed, and variously arranged.;]; This
is the case in all parts of the tumor ; in the more homogeneous basis-
* See Nob. 2660, 2671, 2672, in the Museum of the College of Surgeons.
t Remukably good specimens illustiatiDg this point are in the Museum of the Middlesex
Botpitml
X Some of the best ezaminstions are by Valentine, in his report Repertorium ; and by
BUder, in Walter, Ueber fibrose KiOper der GebArmutter, p. 37.
400 TIBKOUB TDHOEfl.
Bubstance as well u in the intersecting bands ; the nieroaeopic diffc
between these parts conaisting, I think, only in the leu or mora
urangement of the fibrous structure or fibrous sppesnuice of the
But in different specimens, or even in different parts of tlw
tissue appears less or more perfectly formed ; so that, while in
tinct filaments or undulating fasciculi may be dissected ont, in
there is rather a fibrous appearance than a fibrous stmetore. ConnM
too, one finds nuclei or cytoblasts strewn through the sobetaaee of
tumor ; tlie less abundantly, I think, the more perfect is the fibnMi (
racter of the tissoe. But in all those respects, there are not, I think. ■
or other differences among fibrous tumors than in a series of natural fihi
tissues.
With these constituents other elementary tissues are mingled in
fibrons tumors. In those in the uterus (just as in the utem indf]^
smooth or organic muscular fibres are more or leas abundant. I '
not, indeed, seen such a specimen as would qnite justify the mi
" mnscular" tumors, sssigned by Yogel: bnttbeaH^
n(.Hi.« liog of the moscalar fibres, in imitation of the wm|
of the uterus, is usual, if not constant, in thcae t«MH
(fig. 64 A).
In the subcutaneous fibrons tumors, and in teo^l
believe, of the uterine tumors also,t elutie fibna, *iA
all their fully-developed character*, may be iDH^
mingled with the more abundant fibrons tusae. lit
structure of fascia is thus imitated ; and, if wt wm
to call those hut montioDed "muscular" tnmon, thai
should be named *' fascial."
Again, in the fibrous tumors on bones, bone, in mtt
plates or spicula, is often present ; or then nay kt
mixtures of fibrous and cartilaginous tissue. Paanbtfi
also, other mixtures of tissues may occur in what we commonly scerpt ■
fibrous tumors ; but I suppose that a general statement may he trij
made, to the effect that the common characters of fibrons tumors, taAm
I just described, arc usually modified towards an imitation of nwiMii
or near which they are severally placed.
Their structural homology is thus complete ; and I presume tbiy wtj
be equally similar in chemical properties. They yield gelatine on bai%;
but I am not aware of any examination of their other constituents.
To the varieties of the fibrous tumor already named, two mul J*
be added, depending on changes which we may regard as resnlts of t*-
esse or degeneration. One consists in the formation of cysts, the otkv
in the deposit of calcareous and other salts in the substance of the tiraVt
* Vif. H X, Minuu Hnietnie of an ulerins Sbioii tumor. Namnr nooolh m^^
Abrei pKijccI rmm ilie etlgtt of s flbmui tiuua. MaRnilled about 4W limn.
t See Bi<liler, in Waller, I. c, p. 8H. I ti-Te Ioiiih). Hl>a^ in « pubperiioaMl Sbnal''
in ill* iiomicb, vtulin fibres jual cotrMponding with IhOM of tb« Datnial MibpanKBal t^*
FIBB0-CY8TIC TUMORS. 401
Boggesting, severallj, the names of the ^^ fibro-cjBtic," and the ^'fibro-
ciJcareoiis" tumor.
The formation of cysts is not rare in fibrous tumors, especially in such
as are more than usually loose-textured. It may be due to a local
softemng and liquefaction of part of the tumor, with eflfusion of fluid in
the affected part ; or to an accumulation of fluid in the interspaces of the
intersecting bands ; and these are the probable modes of formation of
the roughly-bounded cavities that may be found in uterine tumors. But
in other cases, and especially in those in which the cysts are of smaller
rise, and have smooth and polished internal surfaces, it is more pro-
lable that their production depends on a process of cyst-formation, corre-
sponding with that traced in the cystic disease of the breast and other
<nrganB. The whole subject, however, in relation to the origin of the
eysts, needs further consideration ; and I will speak only of the general
ajqpearance of the fibro-cystic tumors.
First, then, we find certain examples of fibrous tumors thickly beset
with numerous well-defined and lined cysts. This appears to be the
DStore of the " hydatid testis" described by Sir Astley Cooper. The
specfanens that I have seen of it make me think that it is, essentially, a
fibrooB or fibrous and cartilaginous tumor in the testicle, with more or
ksi of cyst-formation in the tumor. For, upon or around the tumor, the
seminal tabes or their remains may be traced outspread in a thin layer,
ud without difficulty separable ; and the substance of the tumor is a dis-
tmet mass of common fibrous tissue with or without imbedded nodules of
cartilage, and with a variable number of imbedded cysts, filled with
pellucid serous or viscid contents. A similar condition may be found,
bat is rare, in fibrous tumors of the uterus. It may be found, also, I
believe, in fibrous tumors in nerves and other parts.
In another set of cases, we find one large cyst existing alone, or far
predominating over all the others in a fibrous tumor. This is most fre-
(pent in the tumors in the nerves,* and in the uterus. In the latter
organ it has peculiar interest, because the cyst, if it attain a great size,
nay be mistaken and treated for an ovarian cyst. Several such cases
have happened. The preparation from one is in the Museum of the Col-
lege (No. 2657) ; the history of which, sent by Sir Edward Home, is,
that it is "A portion of an uterus, in which a very large encysted tumor
had formed. The patient had been twice tapped, and the cyst emptied.
The case was supposed to be ovarian dropsy during life.** In another
case, Mr. Csesar Hawkins, suspecting ovarian disease, drew fifteen pints
of fluid from a great cyst in a fibrous tumor of the uterus. f The patient
died a long time afterwards, and the specimen, which is in the Museum
* See Smith on Neuroma, p. 6.
■ t Medical Gazette, vol. xxxvii. p. 1022. This specimen and others are described by Mr.
Prescott Hewett in the London Journal of Medicine. See, also, on suppuration in these
cjiti, Dr. Roben Lee, in the Med.-Chirurg. Trans, vol. xzxiiu Two remarkable cases of the
26
402 FIBBO-OALCABEOna TUMOBB.
of St. Greorge's IIoBpital, allows an enormone fibrous tnmor in Uie BJe
wall of the uterus, having one vast cavity, and in its solid part tu^
small cysts.
With regard to the fibro-<;alcare<ms tumor, it is to be obeerved thattn
methods of calcification exist ; a peripheral, and an interstitial. In At
former, which is the rarer, an ordinary fibrous tumor is coated with)
thin, rough, nodulated layer of chalky or bone-Iiko Bubstance.* In tL
latter method, a similar substance is deposited more abundantly throng
out the tumor, and is usually so arranged, that by maceration, one ol
tains a heavy, hard mass, variously knotted and branched like a lump t
hard coal. Such a ^m
^'■^" cunen is in the CoQ^
Museum (No. 226): it n
- found in a graveyard, aa
was sent to Mr. HudU
as an urinary calculus. 1
is BQ oval, coral-like nui
about five inches long. 0
analysis, it yielded 18-64
percent, of animal matta
consisting of gelatine, wit
a small proportion of albumen ; and its other chief constituents «a
found to bo phosphate and carbonate of lime, the proportion of carbonal
being greater than in hnman bone.
A similar, but larger, specimen is in the Museum of St. George's H«
pital; and one yet larger in that of the Middlesex Hospital, which hi
been described, with a history full of interest, by Mr. Arnott,J
Now the change which ensues in these cases is not ossification; in
bone, I believe, is not formed in tlie fibrous tumors of the uterus. Tli
change is a calcareous degeneration consisting in an amorphous and di
orderly deposit of salts of lime and other bases in combination with, (
in the place of, the fibrous tis8ue.§ It b represented from Dnseeu
plate, in tho adjacent figure (fig. 55). The process is important, 88 ban
the manifestation of a loss of formative power in the tumor. The calofit
fibrous tumors probably never grow, and are as inactive as the calcific
arteries of old age.||
rame kind are relmcd by Schuti (Ps«ii<lop]!i9m«ii, p. IQS). In one of tliem the hii((e cpt
the ntciine lumor proilucetl ilie greatest enlargement of tbe abdomen that be evet nw.
• Ae in Mus. Coll. Suig. No. 3670.
t Catcareoui deposil in a fibrous uterine tumor ; copied from Duiseau.
J MeUico-ChirurgicHl .Transnc lions, vol. iiiii. p. 109.
S Un ibe appearance of a crysiBlline form in the deposits, see Dusseaa (OnJent. na h
Beenweefeel en Tan Verbeeningen in zacble Deelen, p. 80).
I A remarkable eicmplincation ia in Mi.Arnoti'Bcase. Inforiy year!i,tbe calcified tnm
did not nuwe tbut double its lize.
8UB0UTAKB0US FIBROUS TUMORS. 408
With these degenerations I may mention (though it has probably more
of the nature of a disease), a softening of fibrous tumors, in which, quickly,
md apparently in connexion wkh increased vascularity and congestion,
they become oedematous, and then, as their tissue loosens, become very
soft, or even diffluent, or else break up, and appear shreddy and floccu-
lent. In this state the outer and less softened part of the tumor may
burst, or they may separate or slough.*
The most frequent seat of fibrous tumors is beyond all comparison, in
the uterus. Indeed, we may hold that the fibrous uterine tumors are the
BiOBt frequent of all innocent tumors, if Bayle's estimate be nearly true,
that they are to be found in 20 per cent, of the women who die after 85
years of age. But I shall not dwell on the fibrous tumors in the uterus,
fidly described as they are by Dr. Robert Lee, and other writers of ute-
rine pathology. I will only say, that such tumors may occur near, as
irell as in, the uterus ; but that, in respect of this nearness, they are pro-
bably limited to those parts in which fibrous and smooth muscular tissue,
like that of the uterus, extends ; namely, to such parts as the utero-rcctal
and ntero-yesical folds and the broad ligamcnt3.t
Next to the uterus, the nerves are the most frequent seats of fibrous
tumors. But of these, while I can refer to the splendid monograph by
Br. Smith,]; I will say only that, among the neuromata, the fibrous
tamors reach their climax of multiplicity, existing sometimes in every
considerable nerve of the body, and amounting to 1200 or more in the
same per8on.§
So, too, having in view only the general pathology of tumors, and not
the study of their local relations or effects, I will but briefly mention the
fibrous tumors of bones ; referring for a larger account of these to Mr.
Stanley's Treatise on the Diseases of the Bones, and to Mr. Caesar Haw-
kins's Lectures on their Tumors.||
Leamg these instances of fibrous tumors, the histories of which have
leen so fully written, I will select, for the general illustration of the
whole group, some that are less generally studied ; especially those that
are found in the subcutaneous tissue, and deeply seated near the perios-
tenm, or other fibrous and tendinous structures.
The subcutaneous fibrous tumors^ to which those of the submucous
* The whole of this process is extremely well described in Mr. Humphry's Lectures on
Soigeryj Lecu jLXvii. p. 139.
t It appears, indeed, to be this mixed tissue to which the fibrous tumors particularly
Utach themselves; for they are in close relation with it in other parts besides the uterus:
tg^ in the skin and the submucous tissue of the digestive canal and other parts.
I On Neuroma : folio. Numerous cases are also collected by Moleschott in the Neder-
laodsch Lancet, Nov., 1845.
$ M. Lebert has related a case (Comptes Rendus de la Soc. de Biologic, t i. p. 3) of a
Woman, 66 years old, who had several hundreds of fibrous tumors in difTerent parts of her
nbcntaneoas tissue. But these do not seem to have been connected with nerves.
I Medical Gazette, vols. xxi.-ii.-v.
404 SITBGUTANB0U8 PIBB0U8 TUMOBB.
tissue closely correspond, pass, as I have already said (p. 388), within
sensible gradations into the fibro-cellular. Many may be found that
might deserve either name, just as theve are many examples of natnnl
tissues with the^same intermediate characters ; but it is not yery rare ti
find specimens with all the distinctive features ascribed to the fihroH
tumors of the uterus. These form firm, nearly hard, and tense, roml
or oval masses, imbedded, singly or numerously, in the sabcotaneous bt|
raising and thinning the cutis. They may here attain an immense siiei
as in a case from the Museum of Mr. Listen.* A tumor, weighing up-
wards of twelve pounds, was removed from the front of a man's ned^
together with a portion of the integuments and platysma that covered it
It was fifteen years in progress, and has an aspect, such as, I think, b»>
longs only to a fibrous tumor. Specimens, however, of this size are veiy
rare ; they are commonly removed while less than an inch in diameter.
In microscopic characters the subcutaneous fibrous tumors have the
general properties of the species, but they commonly contain elaslie
tissue, and they are apt, I think, to be lowly developed, having only a
fibrous appearance, or even seeming composed of a uniform blastema
with imbedded elongated nuclei, like the material for the formation of
new tendons (pages 128 and 178).
A peculiar and important character in these fibrous tumors is, that
though they may be completely isolated in every other part, they oftea
adhere closely to the lower siu^ace of the cutis, and that, if in any de-
gree irritated, they soon protrude through it, and form vascular masses
— " fungous growths," as they are called. When this happens they may
bleed profusely, and in a manner which, I believe, is not imitated by any
other innocent tumor.
A woman, 52 years old, was under Mr. Stanley's care with a tumor
that projected through the integuments in the inner part of the thigh, its
base being imbedded deep in the subcutaneous tissue, and its protruding
surface raw and ulcerated. The origin of this tumor was uncertain, but
it had existed more than nine years; it had grown quickly, and had
begun to protrude within two and a half years. From its ulcerated sur-
face hemorrhage frequently ensued ; and the patient stated that at one
time two quarts of blood flowed from it. The tumor was excised, and
large vessels that entered its base bled freely in the operation. It ap-
peared to be a well-marked specimen of a soft and lowly developed
fibrous tumor.
A similar case was under my care in a woman 27 years old. The
tumor, of three years' growth, and protruding over the front of the tibia,
was similarly tdcerated, and used often to bleed ; sometimes it bled
largely, and once as much as half a pint of blood flowed from it. This
also on removal appeared to be a fibrous tumor.
Through the kindness of Mr. Birkett, I saw a specimen, from a much
• Mut. ColL Surg. 223.
DIBP-SBATBD FIBROUS TUMORS. 405
fliore formidable example, of the same fact. A woman, 60 years old,
hid a large pendtdons tumor in the front wall of her abdomen, suspended
JBrt below the timbilicas, and reaching half-way to her knees. Its sur-
face had a very inflamed appearance, and the separation of a slough
from its poBterior part gave issue to such hemorrhage as proved quickly
btal.
The tumor is a large, heavy mass, which was attached to the sheath of
the rectus. It is everywhere firm and tough, except where its substance
appears to have been broken by blood issuing from numerous large ves-
ids that traverse it. Mr. Birkett, who examined it soon after the
patient's death, found its texture certainly fibrous.*
The fibrous tumors that occur in or near accumulated fibrous tissues
are well exemplified, medically, by some of those of the dura mater,
and, surgically, by those which may be found at the tarsus or metatarsus
imbedded among the ligaments and other deep-seated parts. Some well-
marked specimens are in the Museum Of the College. One,t from the
eollection of Mr. Langstaflf, is an oval tumor, six inches long, fixed to
the periosteum of the tarsal bones and to the adjacent parts, and filling
die sole of the foot from the os calcis to the bases of the first phalanges.
It was removed, with the foot, from a nobleman, 35 years old, in whom
it had been observed gradually increasing for thirty years. It has all
die general aspects of the fibrous tumor, as typified in those of the
Qtems.
A very similar specimen is shown in a tumor growing over the whole
length of the dorsal aspect of the metatarsus ;| and with these may be
mentioned one§ which has some historic interest, for it was removed from
the Hon. William Wyndham, the associate and friend of Pitt, and Fox,
ind Burke, — "the model of the true English gentleman." When he
was 60 years old, and an invalid, he exerted himself very actively
one night in saving from fire the library of a friend. During his exer-
tions he fell, and struck his hip ; and from that injury the tumor ap-
peared to derive its origin. It grew quickly, and in ten months it
seemed necessary to remove it. Mr. Wyndham submitted to the opera-
tion, his biographer says, "with neither hope nor fear;*' and it would
be difficult to describe so briefly a more unfavorable state of mind. The
operation was performed by Mr. Lynn. The tumor was attached to the
capsule of the hip, and was with difficulty removed. At first all went
well ; but then, it is said, symptomatic fever came on, and death occurred
on the 16th day. The tumor was, by Mr. Wyndham's request, placed
in the Museum of this College ; and I have had it sketched because it
might be signalized as one of the most characteristic examples of its
kind.
* This specimen was sent to the Museum of Guy's Ho!>pital by Mr. Nason.
t No. 220. The other half of the same is in the Museum of St. Bartholomew's Hospital,
Series xxxT., No. 9. % Mas. Coll. Surg., 219. § Mus. Coll. Surg., 218.
406 FIBROUS TTJHOBB OK BOXB AMD PIEI08TEUH.
I might add several to these caecs, but these may sufGcc f'tr illiuBH
ntrif-" tions of tlic fibroos tumuni cuudkHi
with the dccp-wated librdus tUMiH
All the PiK-cimens that I liare mm
have presented the stmu;; wliiie («ifl
intcrsec-ting a, frmvish or ilull vUki
basis-substiince, the chiiraoteristio bm
ncss, heanne:^ and tension ; ■II, H
mieroscopic examination, have thatd
the tough fibroa* stnicture fir »{'(«■«
ance; all have yielded palatine in bol^
ing. ;
The favorite seats of the filinfl >
tumors of bono and pennsteiim wl)
almut the jaws: on other bone* lii^]
are very rsirc. The CuIK'pe Mns«a j
i», I suppose, eminently rieh in 6)>rai i
tumors connected vith thi- javh fit-
taining as it doeii the chief nf iboi
that were removcl by Mr. Li:>i->n:a
series ilhislrative at once of his admirable dexterity, and of his »>>al
knowlciige of patholc^iy.
These tumors of the jaws may, to both touch and sijiht, pre.'^nt iW
onlinnry cliaractera of the fibrous tumors, as already descrilKil. TJhj
usually aiipriiat'h the rouml or oval sliajic, but are ^■ucrally kiio)i)><-<i «
sujierficially lobcd, or botr^-oidal, as some have called them. TlnTin
firm, dcnae, and heavy. On section, liawevcr, the majority of tWia. I
" Fig. &'■- Scclioii or B Jcpp.»c«ieil fibrou* tumot; from tliu case Jptfribnl in ibe ro.
t Fi([. 07, A. Fibroui tumor wiihin ihe rnmiM of tlio Iow.t jnw. iliniiiirtiiiit «*1 Mi'nJ''*
ii!i WKlli. B. A limilnr minor oii)f;rnwin)! iijioii llic lowi-r jnw. Biiili atp irprcimtnlii
•crlion, one hniror Ihe naluml kizp, rrum fjiecinicns 4t l>t. Darlliokmifw't. B«li o-iuw
urpe>rvci aiul unmixed &biouiu»ue.
FIBROUS TUMOBS IN THE BARS. 407
tliink, are more imiform than the fibrous tumors of other parts. The j are
generally ahnost uniformly white, and scarcely intersected by any distinct
fibrous bands, except such as may divide them into lobes. Many of
them also present, in their interior, minute spicula of compact, white,
bony texture.
As to situation and connexion, the fibrous tumors of the jaws may be
found isolated and circumscribed, growing within the jaw, divorcing and
expanding its walls, and capable of enucleation* (fig. 57 a) ; but, in a
large number of these tumors, the periosteum, with or without the bone
itsdf, is involved or included in the outgrowing mass (fig. 57 b). The diffe-
lence is illustrated by the sketches (fig. 57). In the case of the upper
jaw, either the periosteum, or the fibro-mucous membrane of the antrum
or nasal walls, or both of these, may be included in such a tumor. In
all cases the tumor lies close upon the bone, and cannot be cleanly or
without damage to it separated, except on the outer surface : commonly,
indeed, bony growths extend from the involved bone into the tumor ; and
sometimes the greater part of the bone is as if broken up in the substance
of the tumor.
In all those characters of connexion, the fibrous tumors on the exterior
of the jaws and about other bones resemble outgrowths; they are as if
some limited portion of the periosteum were grown into a tumor over-
lying or surrounding the bone. The character of outgrowth is indeed
generally recognised in the epulis, or tumor of the gums and alveoli ;
bat I believe Mr. Hawkins is quite right in the view which he has
expressed, that the fibrous epulis should be regarded as a tumor growing,
like most of the other fibrous tumoi*s, from the bone and periosteum,
Md continuous with them.f That it is prominent and lobcd is because
it grows into the open cavity of the mouth ; and it resembles gimi only
because it carries with it or involves the natural substance of the gum.
I will refer to but one more set of cases of fibrous tumors ; those,
nsmely, that occur in the lobules of the ears. These are, indeed, trivial
things in comparison with the tumors of the jaws, yet they have points
of interest, in that they grow after injuries, and arc very apt to recur
after removal. They are penalties attached to the barbarism of ear-rings.
* For such cases see the Museums of the College of St. Bartholomew's and Guy's Hos-
piUls; Stanley, lUastrations, pi. 16, fig. 8; Ward, Proc. of the Pathol. Soc. Nov. 10, 1840.
I fl say fibrouM epulis^ because growths may be found resembling common epulis in many
characters, yet differing in some and especially in microscopic structure. M. Lebert clashes
ejmlli with fibro-plastic tumors, and I shall refer in the next lecture to specimens present-
ing the structure to which he gives that name ; but more of those which I have examined
were of a purely fibrous texture. The difierencc may be important in surgery; for there is
always uncertainty about the operations for epulis ; perhaps because among the firm lobcd
oatgrowthfl from the gums and jaws, to all of which the same name iit applied, there are
two or more kinds of tumors, with as many different properties. The lecture of Mr. Haw-
kins (Medical Gazette, vol. xxxvii. p. 1022) is the best study on the subject of epulis. Mr.
Birkett tells me he has found the glands of the gum much developed in some instances of
tumors thus named.
408 VIBROUS TUMORS.
Shortly after the lobules of the ears have been pierced, it
happens that considerable pain and swelling supervene. These
to be followed bj a more defined swelling in the track of the
and this swelling presently becomes a well-marked fibrouB
the lobule of the ear. There may be, perhaps, some doubt wl
the growth be a proper tumor or a cheloid growth of the cicatrii
formed in the track of the wound ; but it has the aspect of a
fibrous tumor, and the skin appears unaffected.
In one case, of which the specimens were presented to the M
St. Bartholomew's Hospital* by Mr. Holberton, a tumor, such as I
described, formed in the lobule of each ear of a young woman, a
months after they were pierced for ear-rings. Both the lobules
off with the tumors ; but, in or beneath one of the cicatrices, a
tumor formed shortly afterwards. This was excised; and in Iks
years that have since elapsed there has been no return of the discsi
In another case, under the care of Mr. Benjamin Barrow, two
tumors formed in the same ear after puncture. One of these wst
away, the other was left : a third grew, and the excision of the
lobule was necessary for the complete extirpation of the disease.
Similar instances are recorded by Bruch,t yensetta,^ and othoi;
but the histories of the cases are so like these that I need not ddril
them.
Among tumors so diverse in their seats and relations as the fibnM
tumors, there are perhaps few things relating to their life that can k
stated as generally true.
In the uterus many may exist at the same time: the whole wtll oft
uterus may be crammed with them, while others project from it into tbi
peritoneal cavity. As Walter and others have observe<l, when a fibrotf
tumor fills the cavity of the uterus, or projects from it into the Tigisi,
it is not usual for another to be found in the walls. Such cases do ii-
dee<l occur, but they are comparatively rare. It is yet much more rare for
fibrotis tumors to be found in any other part at the same time as in tkt
uterus. I find but one such case recorded,; a case by Dr. SutherludJ
in which, with several fibrous tumors in the uterus, one was found in tbi
groin of a lunatic 42 years old. But such a case is a most rare exceptioB
to the rule ; or, indeed, may be more like an example of the rule, if tke
tumor were connected with the round ligament, and the tissue thersB
continuous with the uterus.
In the nerves, as in the uterus, a multiplicity of fibrous tumors mijk
found ; but, so far as I know, the rule of singleness generally prevAib i&
every other part liable to be their seat.
• Ser. XXXV. No. '21. f I^»o Diagnose iler bOsinrtit^on GescbwQlste, p. 'J'JS.
f Annnle* de Chinirgic, Juillet, lb44. *
$ Proceedings of the Patlioiogical Society, vol. ii. p. 87.
MALI0HANT FIBROUS TUMOBS. 409
The development of fibrous tumors is usually, I believe, through nu-
deated blastema.
Their growth is geuerallj slow and painless. It is often very slow, so
that tumors of thirty or more years' standing are found still far short of
the enormoQS dimensions of some of the last species. But no general
nde can be made on this point, especially since the rate of growth is
infloenoed by the resistance offered by the more or less yielding parts
iroond.
The extent of growth appears unlimited ; and among the fibrous tu-
mors are the heaviest yet known. They have weighed fifty, sixty and
Mfentj pounds. The tumor that induced Walter to write his admirable
anay* weighed seventy-one pounds. He refers, also, to one of seventy-
four pounds, and to one described in an American journal as having been
utimated at one hundred pounds ; but he asks of this, perhaps imperti-
nently, whether it were weighed also (aber auch gewogen ?).
In relation to the degeneration and diseases of fibrous tumors, I need
add nothing to what has been said concerning the formation of cysts, the
Cildfication, and the process of softening or disintegration.
And respecting their nature, there can be no doubt that, in general,
ihey are completely innocent. Tet there seem to be exceptions to this
rale, for occasionally, tumors are found in which both general and micro-
wopic characters exactly resemble, I believe, the ordinary fibrous tumors
abetdy described, but which diffier from them in that they recur once
or more after removal, and form ijot only in their first locality, but in
internal parts remote from it. To these, till their characters are more
perfectly known, I would give the name of Malignant Fibrous Tu-
XdBS.
A remarkable instance of these occurred in a poor widow who was
onder my care twelve years ago. She Was 47 years old, and had been
erippled with acute rheumatism for ten years before she found a small
movable tumor in her right breast. This had increased slowly till seven
weeks before I saw her, when, having been struck, it began to grow
Tery rapidly, and became the seat and centre of severe pain. It in-
creased to between two and three inches in diameter, was nearly spherical,
▼wry firm, tense, and painful, — even extremely painful. I supposed it to
be a large hard cancer, and removed the whole breast. I found the
tomor completely separable from the mammary gland, which was pushed
aside by it, but was healthy : the cut surface could not, I think, have
been distinguished from that of an ordinary fibrous tumor of the uterus,
with undulated white bands, except in that part it had a suffused
purplish tingcf The whole substance of the tumor had the same cha-
* Ueber fibrose Korper der Geb&rmutter. Dorpat, 4to. 1 812.
t One section of it is in the Museum of St. Bartholomew's, Ser. xxxiv. No. 24 ; another
in the College Museum, No. 223.
410 MALIGNANT FIBBOI78 TUMOmS.
racters : and in microscopic examination, often and latel j repealed I
could find nothing but tough, compact, well-formed fibroits tiwoe vilk/
imbedded elongated nuclei. On boiling, gelatine was freelj jieUeiji
In short, I believe it would be impossible to distinguish, bj anj mcaai
but the history, this tumor from a common unmixed fibrous tamar dl
the jaw or subcutaneous tissue.
Three months after the operation a tumor appeared under the
It grew very quickly, and felt just like the former tumor. " After vw^
months the thin scar began to ulcerate, and the integuments arooi
sloughed ; and shortly the whole of this tumor was separated by sloojek
ing, and was removed entire. This also had, and, in the Museum of St
Bartholomew's, still retains, every character of the common fibnM
tumor.
After the separation of this second tumor, a huge cavity remaiM^
with sloughing walls; then, as the sloughs cleared away, hard knots, lib
those of a cancerous ulcer, grew up from the walls, and the disease as-
sumed all the characters of a vast and deep hard cancerous sore, h
two months she die<l. I found the ulcer nearly a foot in diameter: m
walls were formed of a thick nodulated layer of hard, whitish, vaficalir
substance, like the firmest kinds of medullary cancer. Both lungs coa-
taincd between twenty and thirty small masses of similar substance i»
bedded or infiltrated in their tissue;'*' and this substance I have recenily
again examined, and found to be a complete fibrous tissue, like that d
the first tumor removed. I found no similar disease elsewhere.
All the characteristic features of malignant disease were thus sllp«^
added to the growth of a tumor which appeared to be, in every sirafr"
tural character, identical with the common innocent fibrous tumor. Nearly
the same events were observed in the following case : — In 1835, a mu
was in St. Bartholomew's Ilospital, under the care of Mr. Earle, wiihi
large spheroidal tumor, lying by the base of his scapula, and extendiBg
beneath it. It was removed ; and I remember that it was easily ent-
clcated from the adjacent parts, and was called "albuminous sarcomif
but it was not preservo<l. About a year afterwards the man rftarMii
with a yet larger tumor in the same situation. Mr. Skey removed ihi-S
together with a large portion of the scapula, to both surfaces of vhick
it was closely united. The wound was scarcely healed, when aDotbcr
tumor appeared, and increased rapidly. With this the patient died, isi
growths of similar substance, white, very firm, and nodulated, were foosd
beneath that part of the pleura which correspon<led with the growth «
tlie exterior of the chest. I state these particulars from memory; but
I have found, from repeated recent examinations, that the tumor removed
by Mr. Skey is of fibrous texture, resembling the common fibrous tumort
both in general and in microscopic characters, and, like them, yicUm?
♦ Muf, St. Bartholomew^ Sor. xiv. No. 43 ; Miis. CoU. Surg , T^A.
NALieHAHT FIBBOOS TttHOKS.
411
gelatine wben boQed.* It is lobed, with partitions of fibro-cellnlar tissue,
and its several lobes are intersectedwith obscure, opaque white fibres: it
is tongh, compact, and heavy, and tears with an obscure fibrous grain. It
is easily dissected for the microscope, tearing into )i,. sg.|
&sincnli, and appears composed wholly of closely- / /j
placed and nearly parallel undulating filaments. A /' ''iL
few ehrivelled nuclei appear among the fibres, but n
cells are distinguishable. Its structure is represented i
hifig.68.
To these cases I may add, though it be an
perfect one, that of a woman from whose back Mr. I
Lavrence removed a large, well-marked fibrous tumor, j
vhicb had grown nine months after one of the same
appearance had been removed from the same partit
Before removal, this was judged by all who saw it to
be malignant ; but it presented a genuine fibrous
Btntcture, and could not, I think, be distinguished from
u ordinary fibrous tumor.
Such are the cases which make me believe that tumors
oecnr, resembling in all respects of structure and chemi-
cal composition the fibrous tumors of the uterus (except-
ing their muscular fibres), or of the bones or subcutaneous
ti8Bae,yetdiffering from these in that they pursue acourse
lile that of cancers, recnrriog after removal, growing at the same time
ID internal organs, tending to sloughing or ulceration, and in the latter
process involving adjacent structures. I have related only cases in
which the fibrous structure wns proved by microscopic examination; but
I have little doubt that others might be added from cases of tumors of
the jaws and other bones, which have been believed, from their general
appearance, to be fibrous, yet have pursued a malignant course. I will
only add that these are not such growths as those which Mullcr and
otheiB have named Carcinoma fibrosum, and of which, I believe, that
they are always infiltrations in the substance of the affected organs, that
they generally include cancer-cells with their fibrous tissue, and that
they have in this tissue such hardness, stiffness, and other peculiarities
of structure, as make it easily distinguishable from the normal fibrous
tissne and its imitation in the fibrous tumors.
• It U in ilie Museum of St BBriholomaw'a
t Elg. 98, Usnie of a malignant fibrous lurn
Srd about 400 timn.
I Hill, of St. Bartholomew's, Ser, xiiv. S3.
Series xxt.y. No. 51.
>i or tlia scapula; described above. MBgni-
413
BBOVRRIVa VIBBOID TUXOBI.
LECTURE XXVI.
RBCUBRIKO FIBROID AVD FIBBO-NUCLEATBI) TUIIOBS.
I
\^
Thb two groups of tumors, of which I propose to speak in
ture, have perhaps no near affinity to the fibrous tumors last deseribii}
yet they resemble them in general aspect ; they have, till within the 1m|
few years, been confounded with them ; and their component strvelm
resemble those that are nidimental of the fibrous tissue. There v3|
therefore, be some practical advantage in making the real contrast W
twcen them appear, by proximity, more striking.
I have proposed the name ^'Bbcur&ikq Fibroid Tumoe" for apo^
of which the chief characteristics are that their general aspect very ebM^
resembles that of the common fibrous tumors ; their microscopie slnMfS
consists of corpuscles caudate and elongated, as if deyeloping into filra;
and the most striking feature in their history is their prcmeneas to
after removal.
A brief account of some cases of this tumor may best illustrate it
The first I saw was from a gentleman, 60 years old, under the
of Mr. Stanley. In 1846, a tumor was removed by Mr. Cockle CrM
the upper and outer part of his leg. It lay dose to the tibia, was il
large as a filbert, and was considered fibrous. Some months aftermb
another tumor was found in the same place, and, when as large as a waln^
was removed by Mr. Hamilton, of the London Hospital, who considered il
^'decidedly fibrous.** In October, 1847, Mr. Stanley removed froa tk
same place a third tumor ; and this I examined minutely. It had tkt
shape, and nearly the size, of a patella; and the note that I made of ill
general appearance was, that it was '^very like those fibrous toBon
which are whitest, most homogeneous, and least fasciculate and giiUci*
ing;*' and that ^^ without the microscope I should certainly have aJM
it a fibrous tumor."
The microscopic enai*
nation, however, showed
peculiar structures (if>
59). The tum<« vn
composed almost entireiy
^
Fif . 63 .•
I
/
of
very narrow,
ekMh
gated, caudate, and oit>
shaped nucleated oeDii
many of which had long
and subdivided termioil
processes. Their contents were dimly shaded ; and in many instaneei
the nuclei appeared to swell out the body of the cell, as in the moit
* Fig. 50, microKopic elemcnu of m recurring fibroid tumor, described mbore. Migniflt'
mbout 400 timet.
RBOURBIira FIBROID TUMORS. 418
elongated grannlation-cells. With these cells were scattered free nuclei,
and gnunouB or granular matter, such as might have been derived from
disiHtegrated cells. Very little filamentous tissue was contained in any
part of the tumor.
Now, in the extirpation of the third tumor, the parts around it were
very freely removed, the periosteum was scraped from the tibia, and
every assurance seemed to exist that the whole cUsease was cleared away.
But, in June, 1848, two small tumors appeared in the subcutaneous
tiasney just below the seats of the former operations. These also were
ranoved, and these had the same fibrous appearance, and the same.
minute texture, as the preceding. Some months only elapsed before in
ike same place another tumor grew ; i. e. a sixth tumor. The patient,
despairing of remedy by operations, allowed this to grow till November,
1850, by which time it had acquired the diameter of between four and
five inehes, and protruded as a large soft fungoid mass from the front of
the leg. Two profuse hemorrhages occurred from it, and made him
earnestly beg that his limb might be removed to relieve him from the
extrme misery of his disease. The amputation was performed, and he
died in a few days.
The tumor* appeared confused with the thin skin over it. It rested
below on the muscles of the leg, but was not mixed with them except at
a Bcar from the former operations. The tumor was milk-white, soft,
and brain-like, except where discolored by efiused blood, and in the ex-
posed parts was soft, pulpy, and grumous. One would certainly, judging
Ij its general aspect, have called this a brain-like medullary cancer ;
and yet it had essentially the same microscopic characters as the tumors
I first examined from the same patient : only, the narrow, elongated,
caudate cells were very generally filled with minute shining molecules,
as if from fatty degeneration connected with the protrusion and partial
doughing of Uie mass. Unfortunately no examination of the body was
made after death, and it could only be guessed, from the absence of
emaciation, and of all other indication of general loss of health, that no
aimilar disease existed in internal organs.
In another case of the same kind, I assisted Mr. Stanley, in May, 1848,
in the removal of a tumor from the shoulder of a gentleman 28 years
old. It had been growing under the deltoid for six months, was loosely
connected with the surrounding parts, and was about three inches in
diameter. It had the general aspect of a common fibrous tumor : firm,
tough, white, traversed with irregular bands. It was easily and com-
pletely removed, but was not examined with the microscope. The wound
of the operation healed well ; but, two months afterwards, a second
tumor appeared under the cicatrix. This was removed with some of the
adjacent muscles, and other tissues. It was like the first, only less tough,
and more lobed, and clastic ; but under the microscope, instead of ap-
pearing fibrous, it was found to be composed almost entirely of elongated
* Jo tbe Museum of St BaTtboloinew'».
414 REOUBRIKG FIBROID TUMORS.
and caudate nucleated cells, very like those described in the tut
and mixed with free nuclei, and granular matter.
In March, 1849, a third tumor was removed from the saiae p^^
which had been noticed two months, and again presented the 10^
character ; it was indeed grayer, and less firm, and more shining ai»
succulent on its cut surfaces, but the differences to the naked eye wtf^
not great, and the microscopic structure was the very same as in dl
former instances.
In October, 1849, another tumor had formed, and after it had reartii
various methods of treatment, Mr. Stanley removed it, by a fourth open*
tion, in December. This had again the same character.
In the course of 1850, a fifth tumor appeared in the same part ai
this, after growing slowly for an uncertain time ceased to incretse, wti
has now been for a long time stationary, without in any way interffri^|
with the patient's health. He is pursuing an active occupation, anl,
but for the tumor, might be thought a healthy man.
In a tliird case Mr. Symo removed, in 1839, a tumor which, witho*
any known cause, had been growing for a year, over the anterior part tf
the first right rib of a gentleman 48 years old. Two years after the ope*
tion another tumor appeared in or near the same part, and was remorei
by Mr. Syme, in 1843. A third was removed by him in 1847 : and §
fourth in 1849. After another distinct interval of apparent health, a CM
tumor appeared and grew quickly, and was removed by the same gentk
man in 1851. In one of these, an account of which was publidied bf
Mr. Syme, Dr. Hughes Bennett found microscopic structiffes similar to
those of the fibro-plastic tumors of Lebert ;* similar, therefore, I have no
doubt, to those described above. The patient recovered from the la*
operation, as from all tlic previous ones, quickly and favorably : but tie
wound had scarcely healed when two more tumors appeared beneath the
scar, like the preceding ones, except in that they grew more rapidly.
One of these tumors was so firmly fixed at the clavicle that no fnrtker
operation could be recommended. In six months* growth the tumors «
first distinct, had formed a single mass, deeply lobed, of oval fona
measuring a foot in one direction and about ten inches in the other.
It covered, and felt as if tightly fixed to, the middle half of tke
clavicle, and thence extended downwards over the chest, and outirftrJ?
towards the axilla. It felt heavy, firm, tense, and elastic. The ?ki«
thinly stretched over it, and by its tension appearing as if tiht
rent, was generally florid, but in some parts livid, and over the m^t
prominent lobes ulcerated; but the principal ulcers were suporfici*!*
covered with healthy-looking granulations, discharging thick pus, haring
no cancerous or other specific character : only one of them had i thin
slough. Such were the characters of the disease when I saw it in Feb-
• Monthly Journal of Medical Science, vol. x. p. 194. Probably this refert to ihe'l**"
frated cells alone. I have not, in any of these tumors, found tlie lar^ many-nuclettfd ctm
which occur in most of the tumors namcii Abr^plastic by M. Lebert.
RBOUBBING FIBROID TUMORS. 415
roary, 1852 ; and it was very striking, as evincing one of the contrasts
between this form of tumor and any rapidly-growing ulcerated cancer,
that the patient's general health was scarcely affected. He was still a
florid sturdy man ; and fed, slept, talked, and moved about as a man in
health might do. He suffered scarcely any pain ; but, within the last
month, the ulcerated surface of the tumor had bled severely. The tumor
was now submitted to compression, with Dr. Neil Amott's apparatus ;
tnd with 'some advantage, insomuch as its growth was retarded, and the
hemorrhage was prevented, so long as the pressure was maintained.
Twice, however, on the instant of removing the apparatus, I saw arteries,
as large as the radial, throw blood in a jet far from the trunk. The
bleeding was in this respect such as I have never seen from the proper
vessels of any other tumor, and was like that described as occurring in
the first of these cases.
It would be useless to tell, at any length, the later history of this
case. The tumor increased constantly to the time of the patient's death
in Jiily, 1852 ; but, in the last two months, several small portions of it
donghed away, and it gradually shifted lower down to the chest, leaving
the clavicular region, so that at the time of death it lay movable on the
muscles, and could be removed, ^^as a common fatty tumor might be,"
lithout dividing any important part : death seemed due to mere exhaus-
tion, consequent on the discharge from the tumor, and the pain to which,
»8 it extended further into the axilla, it gave rise. Dr. Ross, to whom
I am indebted for an accoimt of the conclusion of the case, could find no
indication of disease in any internal organ. Only the tumor was allowed
to be examined after death; and Dr. Ross wrote to me of it, in addition
to the account of the absence of any deep connexion or infiltration of
adjacent tissues, that ^4ts texture was pretty hard, like that of a fibrous
tumor, but not nearly so dense or crisp as scirrhus. It scarcely gave
out any blood on being cut into ; but here and there was to bo seen, on
the surface of a section, the open mouth of a vessel, just as in a section
of liver. All the textures behind, forming the bed of the tumor, appeared
quite healthy."
A portion of the tumor, kindly sent to me by Dr. Ross, was, after having
lain in spirit, milk-white, firm, elastic, of very close texture, breaking
and tearing with a coarse fibrous grain. It had, most nearly, the aspect
of a very firm fibro-cellular tumor altered by spirit. When scraped it
yielded little or no fluid, but white shreds, in which, together with much
that looked like withered tissue or d^ris, there were abundant slender
awn-shaped corpuscles, such as are sketched in fig. 60. They looked
dry and shrivelled, containing no distinct nuclei, but minute shining par-
ticles, as if themselves were outgrown nuclei. With these, also, were
numerous broader and shorter corpuscles, of the same general aspect,
but enclosing oval nuclei ; and yet more numerous smaller bodies, like
shrivelled, oval, elongated, free nuclei, dotted, and containing minute
416
KBOUftmiirO VZBKOID TVMOftf,
flhining paiticleB. The whole mass appesred inado up dl
these yarioiiB ahapes, inregiilarly or linc^j imbedded in a
Fig.««
r
1
was nearly structureless or imperfectly fibrillated. Only in a few
perhaps in the partitions of the lobes, there was a very ammll ^pastA/i
fine fibro-cellular tissue.
I think there can be no doubt that this case was essentially ef Aij
same kind as the former two ; and the constancy of their pecoliaritkiil
both history and structure appears sufficient to justify the placing thi||
in a separate group and under a separate title. But these are sol Al
only cases to bo cited.
Professor Qluge has given a good general account of the hisloiy^-
such tumors as these, as examples of the forms transitional to
He names them '^ albuminous sarcoma ;*' a term one hears freqpflrib
used, without, perhaps, any clear meaning ; yet, generaUy, I thinks Vft
the suspicion that the growths to which it is applied are not wbdlyil
cent. Among the cases which he cites, one coincides exactly with
I have detailed. A major, 45 years old, fell from his horse in 184L
Six or seven weeks afterwards, a tumor appeared over his scapula. K
was removed, but after some months returned. Between 184S and IStf^
four such tumors were removed from the same part. In 1848, the pa*
tient was under the care of M. Seutin, who removed the fifth tumor; lal
Gluge's description of this, including the expression that in cokr ill
consistence it was like the muscular tissue of the intestinal canal, Ieaf0
little doubt that it was like the less firm of the specimens that I ksit
been describing. In the last of these five operations, and in one pn-
viously, the removal of the tumor was followed by free cauterisaUOB tf
the wound ; yet the last account published by Professor Gluge wai» thrt
in April, 1849, a sixth tumor had appeared in the same part ; aad ht
has informed me by letter that in 1850 the patient died.
Lastly, a case which, in its conclusion, is the most instmctive of aD
that have been recorded, is related by Dr. Douglas Maclagan*t
A girl, 22 years old, had a tumor, of three years* growth, on the kft
* Fig. 00, micrcwcopic itructures of the reourring fibroid tumor, Heteribed abova
fied 450 timet,
t Edinburgh Medical and Surgical Journal, vol. xlviii.
RIOUBRING VIBBOID TUMOBS. 417
•
hmbar region, abont an inch from the spine. In 1832, it was about as
large as a Jargonelle pear, firm, but elastic and movable, and below it
was a portion of indurated skin. The tumor and diseased skin were re-
moyed, and the former '^ possessed most of the characters of a simple
fibrous tumor." After about twelve months the disease returned in the
scar. Three little tumors formed, and these, with the scar, were re-
moved freely, in February, 1834. ^^ The extirpated mass bore a striking
resemblance to that previously removed." Between twelve and eighteen
•months later, a third growth appeared, which, after increasing for a year
and a half, was removed. ^^ It had the same elastic feel and fibrous
appearance; and the semi-transparent pinkish-gray color was the same
as in the original tumor." After this operation no fresh growth ensued ;
and Dr. Maclagan informed me, in 1850, that the patient remained per-
fectly well. The portraits of the several tumors, which he very kindly
sent me, make me sure that the disease was, in this case, the same as
in those I have before detailed.
Dr. Maclagan has added the account of another case in which the
essential features were quite similar ; and another, which I believe must
be referred to this group, is accurately described and figured by Dr.
Hughes Bennett.*
These cases will sufiice to prove the existence of a group of tumors
laving these remarkable characters in common : — 1st. A general resem-
Uanoe to the fibrous tumors in their obvious characters ; 2d. A micro-
seopic texture composed, essentially, of elongated and caudate or oat-
shaped cells, somewhat resembling the elongated cells of granulations or of
Ijmph developing into fibres, yet differing from them enough to be easily
distinguished ; 3d. An exceeding tendency to local recurrence after re-
moval, and, in the worst extremity, to protrusion and ulceration ; 4th. An
absence of those events which, in cases of ordinary malignant growths,
would coincide with local recurrence : such as cachexia, independent of
profose suppuration, pain, and other ordinary causes of exhaustion ; and
the absence of all affection of distant parts, or of the lymphatics.
5. Occasionally, a cessation of the tendency to recurrence, and a com-
plete recovery.
How may we interpret this singular proneness to recur ; this tendency
lAich by its existence separates these to some distance from all innocent
tmnors, and by its existing alone separates them as far from the malig-
nant tumors ?
Two views may be taken of the fact.t The tumors may, from the
first, be formed in a cluster or group, and then the removal of one of
* On Canceroas and Cancroid Growths, p. 87.
t Some would add a third, supposing that in all theso cases portions of the tumor were
left behind in the operations. But this is unreasonable. These tumors are not more diffi-
cult to remove wholly than many are which never thus recur, such as the fatty, fibro-cellular,
and the like. Besides, in the cases I have cited, the names of the operators are a sufficient
gnarantee that the whole tumor was every time removed.
27
418 RBCURBING FIBROID TUMOBS.
them only leaves the remainder to continue their growth ; or, 2dlj, tin
apparent recurrence may be a real one, such as we suppose occurs in thi
case of cancers ; in which we presume that, in a first operation, evei]
morbid structure already formed in a part is removed, and entirely mn
growths are produced in the same part.
The former view .is supported by whatever of resemblance exists be
tween these and fibrous tumors, whose proneness to multiplicity is remarl
able ; and by the fact that sometimes, after the removal of one of theii
two, or a more numerous group, have appeared in the same part. T<
the objections to this view appear to me more weighty. If we suppoM
in any case in which six or seven tumors have been removed in sacoeflwx
from the same part, in as many years, that all began to grow at or aboi
the same time, the last of these ought, according to the rate of growth o
the rest, to have come into view much sooner. If the second tumor ww
not discernible in the first operation, where, or of what size, was ik
sixth ? or why did this sixth require many years to attain the same buD
as the supposed coeval second tumor acquired in one year ? It may b
added that some of these fibroid tumors appear to have recurred in ih
substance of a scar left after a former operation ; in a tissue, therefoR
which did not exist at the time of the previous operations.
We must not overlook, in connexion with this apparent aptness to recur
the fact that the later-formed of these tumors may assume more of tin
characters of thoroughly malignant growths than were observed in the
earlier. In the first case I have related, the last tumor was, in geoenl
aspect, hardly to be distinguished from brain-like tumor, though, in micro-
scopic characters, essentially like its predecessors. In one of Profeflsoi
Gluge's cases, the transitions to completely malignant characters appeared
yet more sure. Mr. Syme also expresses a similar transition ; describing,
as the usual course of the cases he has seen, that, after one or two recur
rences of the tumor, the next new productions present a degeneration ol
character, excite pain, proceed to fungous ulceration, and thus in the end
prove fatal. And in all cases, unless recovery ensue, the successifi
tumors increase in rate of growth. So that, although there be cases ii
which this evil career has not been run, yet I think we may regard thflM
tumors as approximating to characters of malignancy, not only in thei]
proneness to recur after removal, but in their aptness to assume men
malignant features the more often they recur. Whatever be the tmtl
concerning the supposed transformation of an innocent into a malignant
morbid growth, I think it can hardly be doubted that, in the cases of sonM
recurring growths, such as these, and certain recurring proliferous cysts
the successively later growths acquire more and more of the characters o:
thoroughly malignant disease.'*'
* See a reference to the same point at p. 364. An illustration is presented by a remark
able case, of which specimens are described in the Catalogue of the Museum of St Butbolo
mew's, Ser. xxzv. Nos. 2S, 29.
VIBBO-NUOLBATED TUMOBS. 419
FIBRO-NUCLEATED TUMORS.
Dr. Hughes Bennett'*' has given the name of Ftbro-wucleated to cer-
tain tumors, first described by himself, of which I think that future in-
yestigations will prove a very near affinity with those which I have been
considering. They are, indeed, of so rare occurrence, that we cannot as
jet be sure of many things concerning them ; but their most usual cha-
racters seem to be, as assigned by Dr. Bennett, a general resemblance to
the fibrous tumors ; a tendency to return in the part from which one has
been excised ; an absence of disposition to affect lymphatics or more dis-
tant parts ; and a texture '^ consisting of filaments infiltrated with oval
nuclei." The first three characters are repetitions of those belonging to
the recurring fibroid tumors ; the last is not so ; and yet the difference
of structure is such as may consist with a very near natural relationship.
For, as we have seen, both cells tending to elongate and attenuate them-
selves into filaments, and nuclei imbedded in a simple or filamentous blas-
tema, are equally forms through which fibro-cellular or fibrous tissue may
be developed (see p. 889, &c.). And thus it may be that, in these two
groups of tumors, the similarly contrasted forms of elemental structure
may be nearly related, in that both alike represent persistently imperfect
developments of fibrous masses.
However this may be, the history of these cases is important, especially
because, like the last described, they seem to occupy a kind of middle
ground between innocent and malignant tumors. They are among the
diseases which are often spoken of as ^^ semi-malignan^," ^' locally malig-
nant," or " less malignant than cancer :" terms which are generally used
in relation to what are deemed exceptional cases, but which may appear
to have a real meaning if ever we can apply them to well-defined groups
of tumors.
The most characteristic of the cases described by Dr. Hughes Bennett
was that of a lady 25 years old, from whom, when she was 18, a tumor
of four years* growth was removed from the left thigh, nearly in front of
the great trochanter. After its removal there remained a small hard
knot in the scar ; but no change ensued in this for six years. Then it
began to enlarge and increase, and in a year increased to the size of a
small almond-nut. It was superficial, quite movable, and intimately
adherent to the skin. It was hard and dense ; and its cut surface was
smooth, slightly yellowish, and yielded no juice on pressure. It appeared
to consist of fine filaments, among which oval bodies, like nuclei with
nucleoli, were everywhere infiltrated. Here and there large oval rings
appeared, marked by converging irregular lines, and, in a few places,
oval spaces surrounded with concentric marks, like sections of gland-ducts.
The only well-marked case that I have yet seen was that of a boy, 10
years old, on the palmar aspect of whose forearm a small indentation
* On Canceront and Cancroid Growths, p. 17G, &c.
420 FIBRO-irUCLBATBD T0M0B8. 1
was noticed at birth. This part vaa sligtitly wounded when he ww tm
years old, and from that time a tumor began to grow. When he wu
four, the tumor was removed (of course completely) by Mr. Sands Cox,
but the wound did not heal before another growth appeared. Tiat m-
creased at first slowly, but at last quickly ; and when the boy came under
my care, it formed an oval swelling, rising to nearly an inch and a half
above the surrounding skin, and measuring from three to three and a half
inches in its diameters. The skin over it was very thin, adherent, tenae,
and florid, and at the centre ulcerated, and superficially scabbed; tlie
ulcerated surface was granulated, like one slowly healing. The tnus felt
firm and elastic, and, at its borders, very tough, like the tissue of a de»-
trix ; IttUe cord-like branching processes extended &om its borders out-
wards in the deeper substance of the cutis ; and above the pruunpal nuHi
another, like a small flattened induration of the skin, was felt. Tim
growth was not painful, and the general health appeared good. Som ■
axillary glands were slightly enlarged.
I removed the whole disease, with all the surrounding skin that appeared
in any way unhealthy, and large portions of the fascia of the foream
and of the intermnsclar septa, to which the base of the growth adhered
intimately, and which were indurated and thickened. • The wound veiy
slowly healed^'; the enlargement of the axillary glands subsided ; and I
have heard from Mr. Oliver Pemberton, under whose care the recoveif
ensued, that the patient remained quite well fifteen months after the
operation.
The tumor was intimately adherent to all the parts adjacent to it,
yet was distinct and separable from them. Its section was smooth and
shining, of atone-gray color shaded
"■■"■• with yellowish tints. It was lobed;
rv J but in its several lobes was uniform,
\) 'a^M^ ^nd with no appearance of fibrous or
^ ' other structure ; but intersected irre-
gularly by white and buff-yeHow
brcnching lines, where the micto-
Bcope found a fatty degeneration of
the tissue. In texture the tumor
was firm, but easily breaking and
splitting in layers, shell-like: with
the microscope it appeared to be
composed of two materials ; namely, nuclei, and a sparing granular or
molecular substance in which they were imbedded. These, as sketched
in fig. 60, were so like those represented by Dr. Bennett, as to leave
little doubt of the similarity of the two caaes ; only there was here less
appearance of fibrous structure, and less of a texture like that of glands.
niRgiufled
CABTILAOIN0U8 TUMORS. 421
The nuclei were, generally, of regular elongated oval shape, from y^Vu to
3^9 of an inch in length, and generally bi-nucleolated ; comparatively
few were broader, or reniform, or irregular. They were very thick-set
in a molecular basis-substance, and in many parts (perhaps in all that
irere not disturbed) they appeared as if arranged in overlying double or
tnple rows, which radiated to a distance from some point, or from some
ipaoe of round or elongated oval form. These spaces, if they were
nch, appeared full of molecular matter.
It would be wrong to endeavor to draw many conclusions from so
mall experience as yet exists on these tumors. I will only express or
repeat my belief (which fully concurs with what Dr. Bennett has stated)
that these are examples of a form of tumor different from any others
jet classified ; and that they will be found most nearly related to the
recmring fibroid tumors.
LECTURE XXVII.
CARTILAGINOUS TUMORS.
Thb name of Cartilaginous Timiors may be given to those which
Muller, in one of the most elaborate portions of his work on Cancer,
has named Enchondroma.* Either term will sufficiently imply that the
growth is formed, mainly, of a tissue like cartilage ; and I would at once
point out the singularity of such tumors being formed, and growing to
BO great a size as I shall have to describe, although cartilage is not com-
monly formed for the repair of its own injuries, nor, at least in man, in
a perfect manner, for the repair of the injuries of bone.
The cartilaginous tumors are found, in the large majority of cases,
connected with the bones and joints.f However, they occur not rarely
in soft parts, completely detached from bone. Thus, in the pure form,
or mixed with other tissues, they arc met with in the testicle,| mammary
* Other names employed are Osteo-chondroma, Chondroma, Benign Osteo-sarcoma. The
tann otteO'tuooma cannot be too entirely disused ; it has been more vague than even Sar-
oooia, having been employed indiscriminately for all tumors, of whatever nature, growing
in or upon bones, provided only they were not entirely osseons.
t Those referred to as connected with the joints are the cartilaginous masses that are
faond pendaloos or loose in joints. They have sufficient characters in common with ihese
tmnora to justify their enumeration in the list ; yet they are in so many respects peculiar,
that they need and usually receive a separate history. The best account of them, and of
their probable origin in the villi .of synovial fringes, may be gathered from Bidder, in Henlo
tnd Pfeufer's Zeitschr. B. iii. ; Rainey;in Proc. Pathol. Soc. ii. p. 140 ; and KAllikcr, Mikrosk.
Anat it p. 324.
J Mat. ColL Surg., Noe. 2384-6-6, &X5. ; Mus. St. Bartholomew's Hosp. Ser. xxviii.. No. 17,
and Appendix; and several in the Museum of St. Thomases Hos])ital. See also Mr. Gam-
jee*s pamphlet, on a Case of Ossifying Enchondroma in the Testicle of a Horse.
422 0ABTILAOIN0U8 TUK0B8.
gland,* snbcutaneons tissne,t and lungs,;]; and in the soft parts near
bones ; but among all the soft parts their favorite seat appears to be the
neighborhood of the parotid gland. The greater part of the solid tomon
formed in this part have cartilage in them.
Cartilaginous tumors that are connected with bones may, like fibrous
tumors (p. 407, fig. 57), occur in two distinct positions ;. namely, within
the walls, or between the walls and the periosteum : rarely they grow in
both these positions at once. When they are within the bones, they are
isolated and discontinuous, and are surroimded by the bone-walls, which
may be extended in a thin shell or capsule around them, or may be
wasted and perforated by them. When they grow outside the bones,
they are generally fastened to the subjacent bone-wall by outgrowths of
new bone ; the periosteum, greatly overgrown, invests them, and prolon-
gations from it towards the bone appear to intersect them, and divide
them into lobes. When they grow among soft parts, they have a well-
formed fibro-cellular or tougher fibrous capsule, which is commonly more
dry and glistening than that of most innocent tumors.
In any of these situations, cd,rtilaginous tumors may be either simple
or complex, conglobate or conglomerate, if we may adopt such terms;
t. e,y they may be composed of a single mass without visible partitions,
or, of numerous masses or knots clustered, and held together by their
several investments of fibro-cellular tissue. According to these conditioDS
they present a less or more knotted or knobbed surface ; but in either
state they affect the broadly oval or spheroidal shape (fig 71).
To the touch, cartilaginous tumors may be very firm or hard, espe-
cially when they are not nodular and their bases are ossified. In other
cases, though firm, they are compressible, and extremely elastic, feeling
like thick-walled, tensely-filled sacs. Many a solid cartilaginous tumor
has been punctured in the expectation that it would prove to be a cyst.
The knife cuts them crisply and smoothly ; and their cut surfaces pre-
sent, in the best examples, the characters of foetal cartilage; bright,
translucent, grayish, or bluish, or pinkish white, compact, uniform. Usu-
ally, each separate mass or lobe is without appearance of fibrous or other
compound structure ; but, sometimes, the cartilage looks coarsely granu-
lar, as if it were made up of clustered granules. This is, I think, espe-
cially the case in the cartilaginous tumors inclosed in the bones of the
hands and fingers ; especially in such of them as are soft. In other
cases, when the cartilage is very firm, it may be opaque or milk-white.
In different examples of cartilaginous tumor there are great varieties
of consistence or firmness. Some appear almost diffluent, or like vitreous
humor ; some are like the firmest foetal cartilage ; and all intermediate
gradations may be found : but, with the exception of the cartilaginous
• Astley Cooper, Diseases of the Breast, p. G4 ; MQller, On Cancer, p. 149, No. 13, from a
dog; Mus. St. Bartholomew's, Ser. xxxiv., Na 13, from a bitch,
t Rokiiansky, Patliol. Anat, B. i. p. 261 ; Lebert, Abhandlungen, p. 195.
f Mus. St. Bteirtliolomew's, Pathol. Appendix } Rokitansky and Lebert, 1. o.
CAKTILAOINODB TUMOBB. 4%S
{Towths that are pendnlona or loose in joints, I have nerer seen anj pre-
wnt ancli hardness, dnlness, or yellowness, as do the natural adnlt car-
tilages of the joints, ribs, or larynx.
As, in all general appearance, the material of th^e tumors, in ita
vaal and meet normal conditions, is identical with fcetal cartilage, so ia
i^ I believe, in its development, and, as Mizller has shown, in its chemical
diaraoters.* The microscopic characters, also, of cartilaginons tumors
tgree, speaking generally, with those of fcetal cartilage ; yet there are
teveral particulars to be observed concerning them, and, especially, the
^versity of form and arrangement, that may be seen in the microeeopic
constitnents of ^ven different parts of the same tumor, needs mention.
This diversity of microscopic forms is enough to baffle any attempt to
describe them briefly, or to associate them with any corresponding exter-
nal characters in Uie tumors. The most diverse forms may even be seen
ade by side in the field of the miscroscope. But this diversity is impor-
tant It has its parallel, so far as X know, in no other innocent tnmor;
and the cartilaginous tumors form perhaps the single exception to a very
generally tmo rule enunciated by Bmch ;f namely, that it is a characte-
ristic of the cancerous tumors, and a distinction between them and others,
thst they present, even in one part, a multiformity of elementary
■luqKs.
The diversity of microscopic characters extends to every constituent
itrneture of the cartilage in the tumors. I will state the general and
diief results of the examinations of fifteen of the recent specimens,^
of which I have made notes, and the drawings from which the annexed
figures were copied.
(1) In r^^d, then, to the basis or intercellular substance: — It is
Tiriable in quantity, the cells or nuclei in some specimens lying wide
apart (fig. 62), in some closely crowded (fig. 63, &c.): it varies in
* Tbe enchondRnnala of bones, he wy>i always yield chondrine ; wbilo those of toft
para may yield nlher gelBline or chondrioe (On Cancer, p. 134). The whole account of
Iheii luulyiis ii veiy amply given by him.
t Die Diagnoae dei bOsaniKo GeBchwQlete.
j Tlieie are exclusive of specimens of loose canilages in joints; of which, indeed, no
■ceonDt will be given in Ibis lecture.
i Rg. 62, Tafled, pale, fllamentoue tissue, with a few imbedded cartilage^iells. From
a tamor over the paiolid gland.
I Fig. 63. Stconger and denser flbro-oartilBgino™ tiasue ; many of the cartilaginous cells
having |raimlaled ninlei. From a tumor over the parotid glanil, magnifled 400 times.
434
UICE06C0FI0 BTBDOIOBIB
ooDsiBteuce, ■with all the gradations to which I have ah*eady referred :
and in texture, — ^in some specimens, it is pellncid, bjraliiie) scarcely nn-
ble ; in some, dim, like glass breathed on ; in many more, it is fibroos in
texture or in appearance (fig. 62, 63). Most cartila^ons tumors, in-
deed, might deserve to be called fibro-c&rtilaginous. It is seldom, and,
I think, only in the firmest parts or spedmens, that the Bubatince be-
tween the cartilage-cells has the strong hard-lined fibrous texture which
belongs to the chief natural fibrous cartilages; yet it has generally •
fibrous texture. The fibres are, or appear, usually soft, nearly pellucid,
and very delicate: sometimes they appear tufted or fasciculate (fig. 62);
sometimes they encircle spaces that contain each a large cartilage-cell,
or a cluster of cells or nuclei (fig. 64) ; sometimes they form a fasdcii-
lated tissue in which cartilage-cells bi
elongated and imbedded (fig. 63); mart
commonly of all, I think, they corn
among the cells, as if they were derind
from a fibrous transformation of an
mtercellular hyaline substance (fig. 66).
(2) Yet greater varieties may be found in the characters of the carti-
lage-cellB-t In plan of arrangement tbey may be irregularly and widely
scattered, or closely placed, or almost regularly clustered with fibrow
tissue encircling them (fig. 62, 64, 65). In single cells there are varifr
ties of size from ^ioth to THooth of an inch. And there are yet more
varieties of shape ; some have the typical form of healthy preparatory
cartilage-cells, being large, round, or pval, or variously shaped through
mutual pressure, faintly outlined, with single nuclei, and clear contents
(fig. 66) ; and some are like normal compound cartilage-cells (fig. 65).
• Fig. 64. Groups of caHilagO-cellB, elurteted in ■ ponion oTa tumor on the phalBiix ofi
flnger. Many of ihe cells sro only <)iawn in outline; llie group) are intenecled by bandi
of toagh, fibrous tiuiia ; some or the cells preient double or triple contour lines ; most of
the nuclei Bie large and granulHi. Magnified about 400 timea.
t Fig. C5. A group of large cBnilHge.celte from Uie same; many ccnttaiiuiig two or ibtM
nuclei, of wbicb some liave acquired ihe characlei of enclosed cells.
{ I retain ihii name, although the obserVHtioni of Bergmann (De CaitilBKinibus, 1H90)
and olberB show that it it difficult, in some cases, to determine the natoie of the cell-contents,
and thai iheic nuclei may be more like cells, or, having had the characleri and relaiiiHU of
nuclei, may acquire those of included nuclealed-cells. Taking, as Ihe type of cartilage-o^
the elements of the chorda dorsalis, I think we shall least otlen eit if wo keep the term tt&
RaliUMB elemenlaiy eiructures in other caTtilagea which are most like the cells of the chorda,
in ^eii fine clear outline, and the pellucid or dim space just within, or, also, just without iL
or OASTILAOmrOUBTUHORS.
425
But, with nrioDS demtiona from these more nonnal characters, eome
tdls hftTO hard dark ontlmes ; and some are bounded by two, three, or
fif. M.* ng. M 1.
four dotted or marked concentric circlee, as if the cell-waUs had become
lafflinated (fig. 64, 65] ;_ others appear without an; defined cell-walls, as
if the; were mere cavities ^^ ^t
hollowed ont in the baais-sub-
Btanee; and, in other instances,
the ceQ-wallfl and their con-
tcDta, down to the nucleus,
■ppear as if they were com-
jJetely fused with the basis-
nlistance, ao that the nuclei / ^
ilone appear to he imbedded
in the hyaline or dimly fibrous material. These last two states appear to
k connected with very imperfect development or with degeneration ; for
I We seen them, I think,
■ ID only soft cartilage, or in rig.M.t
BDch as showed other dis-
tinct signs of dcgcQcratioD.
Id many such oases, also, the
anclei are so loosely con-
Bected with the basis-sub-
itance, that large nntnbcrs
of them float free in the field
of the microscope.
(3) The varieUes of the nuclei in the cartilage of tumors are not less
than those of the cells. Some are like those of the normal cartilage ;
' Fig. 60. Gump of CBTIilRge-cella from b tumor in the tibia. Fine illanienlous liisue
eacTrelei and iQterTen« between aingla celli. Some of the nuclei of the cells contain oil-
jajiictD*; and tome of Ibc same (in fig. G6 a) »bow-, apparently, tliB process of asauming
Ihe steiLate or branched form. Mngnifled 400 times.
tFig. 6T- Free nuclei; some simple, and some enlarged, and Tarioiiaty set wiili bmnching
pToceuei. From a canilaginous tumoi unijer tlie angle of the lower jnw. MagniDeil 400
X Fig. 68. Similar nuclei nirioua l]r ilistoited and shrivelled. From a mixed cartilaginoui
tumor oTsi the panxid j similarly niagnilled.
r-fvf"-
Vf
y
426 KICROBCOPIO STRUCTUBIS
round or ovaI,^lear, distinctly outlined, with one or two nucleoli (fig. 65).
But some appear wrinkled or collapsed, as if shrivelled ; some containiiig
numerous minute oil-particles, representing all the stages to complete
fatty degeneration, and the formation of granular bodies (fig. 63, 66);
some are uniformly but palely granular, like large, pale corpuscles ci
lymph or blood ; some are yet larger, nearly filling the cells, pellucid,
like large, clear vesicles with one or more oil-particles enclosed ; and
some have irregularities of outline, which are the first in a series of gra-
dational forms, at the other extremity of which are various stellate,
branched, or spicate corpuscles (fig. 66 a, 67, 68).
I have not been able to discern any constant rule of coincidence be-
tween these forms of nuclei and the various forms of cells, nor between
either and any of the enumerated appearances of the intercellular or
basis-substance. All modes of combinations have appeared among them;
only, on the whole, the completely developed cells have the best nuclei,
and the degenerate or imperfect of both are usually in company.
The last-named nuclei, with irregular outlines, deserve a more parti-
cular description, both because they are, so far as I know, found in no
normal cartilage in any of the vertebrata, and because their imitating, in
some measure, the forms of bone-corpuscles, might wrongly suggest thtt
they have a constant relation to the ossifying process.
They were first described, I think, by Miiller ; and have since been
noticed in cartilaginous tumors by Mr. Quekett, and many others. I
have examined them in seven cases ; and, to show that they are not
peculiar to one form of cartilaginous tumor, I may add that, of these
seven, one was a great tumor encircling the upper part of the tibia, one a
growth on the last phalanx of the great toe, one a mixed tumor in the
articular end of the fibula, one a very soft tumor in the subcutaneous
tissue on the chest, and three were mixed tumors over the parotid or sub-
maxillary gland.
The phases of the transformation by which they are produced appear
to be, as represented in fig. 66 A-7-8, that a nucleus of ordinary form,
or with one or more oil-particles, enlarges and extends itself in one or
several slender, hollow, and crooked processes, which diverge, and some-
times branch as they diverge, towards the circumference of the celL
Such nuclei may be found within the cells (fig. 66 a), or within cavities
representing cells whose walls are fused with the intercellular substance;
but much more commonly it appears as if, while the nuclei changed thdr
forms, the cells and the rest of their contents were completely fused with
the intercellular or basis-substance, so that the nuclei alone appear
imbedded in the hyaline or pale fibrous substance. The nuclei thus en-
larged may appear like cells, and their nucleoli may be like nuclei. But
although at first, as we may suppose^ the nuclei, as they send out their
processes, may enlarge and retain the round or oval form of their central
parts or bodies, yet they afterwards lengthen and attenuate themselveSi
OF CABTILAGINOUS TUMORS. 427
80 ta to imitate yery cloeel j the shapes of large bone-corpuscles or lacunae ;
cr they elongate and branch or shrivel up ; and in these states, lying in
groups, they have the most fantastic appearances (fig. 67, 68). In these
TBiious states the nuclei are often loosely connected with the basis-sub-
stance ; so that they are easily removed from it, or are found floating on
the field of the microscope, as nearly as those were which are here
drawn.
Now, as I have said, corpuscles like these exist permanently in no
normal cartilage yet examined, in man or any of the vertebrata.'*' If,
then, heterology of structure were indicative of malignancy, the tumors
that contain these corpuscles should be malignant ; but there are no facts
to make it probable that they are so ; and every presumption is in favor
of their being innocent.
As to the meaning of these changes of the nucleus ; — they may be, as
Mr. Quekettf has shown, preparatory to ossification, and the metamor-
pliofiis of the cartilage-nucleus into a bone-corpuscle or lacuna ; but in
many instances they are unconnected with ossification ; for, in most of the
cases in which I have found them, the tumor was in no part ossified, and
in many of them it was not of a kind in which ossification was likely to
enrae. In these cases we may believe the changes of the nuclei to be
connected with a process of degeneration. There are many grounds for
this; such as the fact, already mentioned, of their likeness to the nuclei
of lower cartilages ; their likeness in shape to ramified pigment-cells and
bone-corpuscles, which have probably lost all power for their own nutri-
tum ; the frequent coincidence of more or less fatty degeneration in the
nodei thus changmg ; the usual coincidence of the fusion of the cell-wall
ud contents with the basis-substance of the cartilage, and the loosening
of the nuclei; and the gradual shrivelling or wasting of the nuclei after
the assumption of the stellate form.
Such is the anatomy of cartilaginous tumors ; and now, in relation to
their physiology, several points may deserve notice.
Their rate of growth is singularly uncertain. They may increase very
slowly. I have seen one not more than half an inch long, which had
been at least four years in progress. Or, after a certain period of in-
crease, they may become stationary ; as often happens in the tumors that
occur in large numbers on the hands. Or, from beginning to end, their
growth may be very rapid. I remember a man, 26 years old, in St. Bar-
tholomew's Hospital, in whom, within three months of his first noticing
it, a cartilaginous tumor increased to such an extent that it appeared to
occupy nearly the whole length of his thigh, and was as large round as
* The only natural cartilage yet known as possessing these corpuscles is, I believe, that of
^ cnttle-fish (Quekett, in Histol. Catal. of Coll. of Surg. PI. vi. fig. 7); and it is at least inte-
resting, and may be importantly suggestive, to observe that the morbid structure, deviating
fiom what is natural in its own species, conforms with that of a much lower creature.
t Lectures on Histology, p. 16G.
428 GROWTH AND OTHER OBAVBMB
my chest. He had a pale, nnhealth j aspect, and suffered much from tk6
growth ; and its size and rapid growth, the tension nearly to ulceration
of the skin over it, the enlarged veins, and loss of health, made all sup-
pose it was a great cancerous tumor. Mr. Vincent, therefore, dedded
against amputation of the limb, and the patient died exhausted, witlun
six months of the first appearance of the disease. The examination after
death proved that a great cartilaginous tumor, with no appearance of Cii^
cerous disease had grown within and around the middle two-thirds of the
femur. The bone, after extension by the growth within it, had been
broken, and all the central part of the tumor was soft, nearly liquid, and
mixed with fluid blood and decolorised blood-clots.
In another case, under Mr. Lloyd's care, a cartilaginous tumor, B1l^
rounding the upper two-thirds of a girl's tibia, grew to a circumferenoe
of two feet in about 18 months. Gluge"*" also mentions a case in which,
in a boy 14 years old, a cartilaginous tumor on a tibia grew in &} montb
to the size of a child's head, and protruded, and caused such pain anl
hectic, that amputation was necessary.
I need only refer to the importance of these cases in their bearing oa
the diagnosis of tumors, and as exceptions to the general rule that tlie
malignant grow more rapidly than the innocent.
In extent of growth, the cartilaginous tumors scarcely fall short of the
fibrous. Mr. Frogley f has related two cases of tumors of enormous aie.
In one, the patient was a young woman 28 years old, and the tumor, of
nearly five years' growth, around the shaft of the femur, extended from
the knee-joint to within an inch of the trochanters, and measured nearly
three feet in circumference. It was a pure cartilaginous tumor, but its
whole central part was soft or liquid, and many of the nodules of which
it was composed had the character of cysts, through such central softness
as I shall presently have to describe. The limb was removed near the
hip-joint, and the patient has remained in good health for seventeen yean
since.J
In the other case by Mr. Frogley, the patient was a lady 37 years old,
and the tumor had been growing eleven years ; it was 20^ inches in cir-
cumference, and exactly resembled that in the former case. The ampu-
tation of the limb was equally successful.
The tumor in Mr. Lloyd's case, to which I have just referred, mea-
sured 24 inches in circumference. But all these are surpassed by an
instance related by Sir Philip Crampton, in which a tumor of this kind
surrounding the femur, and soft in all its central parts, measured no lees
than 6^ feet in its circumference.
* Pathologjsche Anatomie, Lief. iv.
t Medico-Chirurgical Transactions, vol. xzvi.
f I have to thank Mr. Frogley for affording me this information, and Mr. Lane for an op-
portanity of exhibiting at tlic Lecture the remarkable specimen obtained by the operatioD,
and now preserved in his Museum.
IK OABTILAQINOUB TDH0B8.
The onlj change of csrtilaginooB tomors vhich can be spoken of as a
derelopment, ia their ossification : and thb is, I believe, in all eeeeutial
■nd minate charactem, aa imitation of the ossification of the nataral car-
tilages.
Bat the more general or larger method of ossification must also be
obserred. Oesifioation may ensue, I sappose, in any cartilaginons tumor ;
but it IB rare or imperfect in those that grow within bonea, and is yet
mttn imperfect, and is like the deposit of amorphous calcareouB matter,
in those that lie over the parotid gland. It is best seen in those that lie
wpaa. or Bnrronnd the bones ; and in these, two methods of ossification
may be noticed.
Ll one method, the ossification begins at the surface of the bone, where
the cartilaginona tumor rests on it, and thence the new-formed bone
grows into the cartilage. Thus, the ossification may make progress far
into the snbstance of the cartilage ; and the tumor may appear like an
outgrowth of bone covered with a layer or outer eruat of cartilage, on
whidi the periostenm is applied. Or, extending yet further, the cartilage
nay by this method be wholly ossified, and the cartilaginous may be
tnniformed into an osseous tumor.
In the other method of ossification, the new bone ia formed in the
nid-Bubstance of the cartilage. In a large tumor the process may com-
nenee at many points, and, extending from each, the several portions of
new bone may coalesce with one another, and with that formed in the
fint method, like an outgrowth from the surface of the original bone.
Indeed, this twofold method of ossification is commonly seen in the large
tomora that surround long bones.
The ossification ensuing ''■- "■'
in several points, and
thenci extending, is plain-
ly, in these tumors, an
imitation of the natural
oaeification of the skele-
ton from centres in each
of its constituent parts.
Sometimes, indeed, this
natural process is imita-
ted with singular exact-
ness. Thus, in the Col-
lege Museum, T^o. 207 is
a portion of a large tumor
which was taken from the
front of the lumbar ver-
tebrae of a soldier. Half of it is cartilaginous, and half is medullary
cancer. The cartilaginous portion consists of numerous small noduloa of
II and cancerous nimoc deicribed in Itie text : reduced
\
480 GROWTH AND OTHER OHAKeiS '
vaxious shapes, each of which is invested with a layer of fibro-celliilir
tissue, as its perichondrium. In many of these, a single small portion o(
yellow cancellous bone appears in the very centre, each nodule osuf jing
from a single nucleus or centre, as orderly as each cartilage of the foetal
skeleton might ossify.
I shall speak in the next lecture of osseous tumors, and among them,
of those that are formed by these methods. It may therefore suffice for
the present, to say that, in nearly all cases, the bone formed in cartil*-
ginous tumors consists of cancellous tissue, with marrow or medullaij
substance in its interspaces ; and that when the ossification of the turner
is complete, the new cancellous tissue is usually invested with a thin oon-
pact layer or outer wall of bone, which, if the tumor have grown on i
bone, becomes continuous with the compact tissue of that bone*
The principal defect or degeneration noticeable in cartilaginous tnmon
is manifested in their being extremely soft, or even liquid ; a clear, jd-
low, or light pink, jelly-like, or synovia-like material appearing in the
place of cartilage. I call it a defect or degeneration, because it is not
always certain whether it is the result of cartilage, once well formed,
having become soft or liquid, or, whether the soft or liquid material be
a blastema, which has failed of gaining the firmness and full organintion
of cartilage. It is quite probable that the same defective structon
would be found in arrests of development as in degeneration ; and the
history of the cases agree herewith. The conditions in which extrene
softness is sometimes found can leave little doubt, I think, that it is in
these cases a degeneration, — a liquefaction of that which was once more
perfectly nourished ; but, in other cases, the softness of structure appears
to have characterized the growths from their earliest formation ; such,
probably, was the case of which the history is told at p. 431 ; but in
many cases we have no guide to the interpretation of the peculiarity.
The soft material of cartilaginous tumor is like melting, transparrat,
yellowish, or pale pinkish jelly ; or like a gum-like substance, or like
honey, or synovia, or serum. Such a material may occupy the whole
interior of a cartilaginous tumor, one great cavity, filled with it, being
found within a wall of solid substance.* Or the whole mass of a tumor,t
or its exposed surface^, may be thus soft or liquid. Often too, we may
trace, in individual nodules of a cartilaginous tumour, a process of what
I suppose to be central softening, by which, perhaps, the formation of
the great central cavities of the large tumors is best illustrated. Thos,
in the tumor of cartilage and medullary cancer, of which I have already
spoken, as illustrating the process of ossification from a centre in each
* Aa in Mr. Frogley's case ; and as in many nodules of the tumors, No. 207 and others,
in the Museum of the College of Surgeons.
t See a drawing of one in the hand, and a specimen in Ser. 1, 115, in the Museum of St
Bartholomew**, and the specimen lately given to the Museum by Mr. Bickersieth, aod
described in page 432. ^ Mus. Col. Surg., Na 206.
IN 0ABTILAGIN0U8 TUMORS. 431
nodule, there are many nodules, in the centre of which, instead of bone,
small cavities full of fluid are seen. So, too, in a large cartilaginous
tmnor, growing on the pelvic bones of a man 40 years old, a portion of
which was sent to me by Mr. Donald Dalrymple, I found a large num-
ber of distinct nodules, each with a central cavity full of honey-like fluid:
and the state of the cartilage around these cavities, its softness, the
fbuon of its cell-walls and their contents with its hyaline basis, and the
sparing distribution of nuclei in it, make me believe that the softness* and
liquefaction were the results of a degenerative process.
When the softening may be safely regarded as degenerative, it is still,
often, very difficult to say to what the change is due. In some cases it
appears connected with the great bulk of the tumor, and the hindrance
to the sufficient penetration of blood to its central parts. Hence it is, I
think proportionally more frequent in the large than in the smaller
tomors. In some cases it may be due to exposure of the tumor, as in
the instance of a cartilaginous tumor which grew from the sacro-iliac
symphysis and adjacent bones, and projected into the vagina of a woman
34 years old.* But in many more cases we are unable to assign a reason
for such softness.
The central softening of single nodules of cartilaginous tumors may
extend to the formation of cysts ; for when the whole of a nodule is
liquefied, the fibro-cellular investment may remain like a cyst enclosing
the liquid. This change was shown in the same tumor as illustrated the
central ossification and the central softening. And it was not difficult to
trace in it what appeared like gradations from central to complete lique-
faction, and from a group of cartilaginous nodules to a group of cysts
with tenacious fluid contents.
When extensively softened or liquefied, or when almost wholly trans-
formed into cysts with viscid contents, the cartilaginous tumors are very
like masses of colloid cancer :t so like, that the diagnosis, without the
microscope, might be nearly impossible. Such a tumor was sent to me
by Mr. E. Bickersteth. A woman, 45 years old, had two tumors, one
on the eminence of the right frontal bone, the other half an inch below
the right clavicle. The former was globular, as large as a walnut, and
fixed to the bone. It felt soft and doughy, but at its base and around
its margins it was hard. The latter was about twice as large, subcuta-
neous, and freely movable ; it felt like a fatty tumor, except in that it
was not distinctly lobed, and was less firm and consistent than such
tumors usually are. Both tumors had been gradually increasing for
eight years, and had been painless. The patient's mother had died with
hard cancer of the breast.
The tumor below the cavicle was removed. It was an oval mass in-
* Mas. Coll. Sarg^ No. 206.
1 1 believe they have been often described as such. I think, too, that some of them are
included by Vogel in his group of " gelatine-tumors" (GallertgcschwQlste), of which he says
gelatinifonn cancen are the most frequent forpi.
482
OROWTH AND OTHER CHAKGIS
vested by a thin fibro-cellolar capsule, partitions from which intersected
it, and divided it into lobes of unequal size, distinct, but closely packei
They all consisted of a soft, flickering, yellow, and pale ruddy substance,
widely intersected with opaque-white lines. The substance was extremely
viscid, and could be drawn out in strings, sticking to one's fingers, like
tenacious gum. Its general aspect was very like that of a colloid caa-
cer, but it had no alveolar or cystic structure, and it was an isolated
mass, not an infiltration. Portions lightly pressed (for it needed no dis-
Ilg. 70.
B
section for the microscope) showed as in the annexed figure (70), together
with a small quantity of common fibro-cellular tissue and fat, a peculiar
filamentous tissue in curving and interlacing bundles, and in separate,
very long and very tortuous, or curled filaments, or narrow flat bands
(a). The latter appeared as peculiar pale filaments, about Tsiov of ^
inch in diameter ; in shape and mode of coiling resembling elastic fibres,
but not having dark edges, and extending to an extreme length. Such
fibres lay imbedded in a pellucid viscid substance, and more abundantly
scattered in the same were various corpuscles (b). Of these some were
simple, others of more complex forms. The former were, generally,
nearly round, dimly nebulous, with one or two shining particles, but
(unless in a very few instances), without nuclei. These seemed to be
free nuclei, of which many had grown to an imusual size, and measured
i^J5 of an inch in diameter. The more complex had the same texture
as these, and seemed to be also altered nuclei, and resembled most nearly
the stellate nuclei of more ordinary cartilaginous tumors. They gene-
rally had an oval, or round, or angular body or central part, from which
slender processes passed out. These followed various directions. Some
were short ; some branched once or more ; some were extremely long,
and appeared to connect adjacent corpuscles, or to be continued into
some of the tortuous bands or filaments, like which, as they extended
CARTILAOIKOUS TUMORS OF THB BONBS. 488
fbrther, they became pale, clear, and finely edged. The chief and ex-
treme forms are sketched, and many intermediate between these existed.
Since the operation the patient has remained well, and the tumor on
the head has been stationary for four months ; so that, thus far, the his-
tey has confirmed the only opinion I could form of so strange a tumor,
namely, that it was composed of immature soft fibrous cartilage, not only
arrested, bat in a measure perverted in its development.
The softened central parts of cartilaginous masses are apt to be
affected with rapid sloughing or suppuration. Such an event occurred
in Sir Philip Crampton's case already quoted, and in one, presenting
many features of great interest, which was under Mr. Lloyd's care, at
Baint Bartholomew's Hospital.* A girl, 14 years old, was admitted with
a very large tumor round the upper two-thirds of the tibia. It had been
growing for 18 months, and shortly before her admission, without any
eTident cause (unless it were that it had been punctured), the integu-
ments over it began to look inflamed and dusky. The limb was ampu-
tated almost immediately after her admission ; and the tumor presented
in its interior a large cavity with uneven broken walls, filled with brown-
ah serous fluid of horribly offensive putrid odor. The inner surface of
the walls of the cavity appeared also putrid, and gases, the products of
the decomposition, were diffused in the cellular tissue as far as the middle
of the thigh.
Other changes of a degenerative character may be sometimes observed
in cartilaginous tumors. Parts of them may appear grumous, or pulpy,
and of an ochre-yellow color.f This is probably a fatty degeneration
of their tissue. And, sometimes, as I have said, their ossification is so
imperfect as to be more like a fatty and calcareous degeneration, in
which their substance becomes like fresh mortar, or soft chalk, and, when
dry, is powdery, and white, and greasy.J
It may serve for additional illustration of this general pathology of
cartilaginous tumors if I describe now some particular forms of them.
I have said that they chiefly affect the bones. The bones of the hands
are their most frequent seats ; and next to these, the adjacent extremi-
ties of the femur and tibia, the parts which, for some inexplicable reason,
appear to have in all the skeleton the least power of resistance of disease.
After these, the humerus, the last phalanx of the great toe, the pelvis,
and the ribs, appear most liable to cartilaginous growths; and after
these, the number of cases is as yet too small to assign an order of
frequency, but there is scarcely a bone on which they have not been
seen.
* It is fully reponed in the Lancet, Dec^ 1850. The specimen is in the Museum of the
HospicaL
t Mus. ColL Surg^ No. 200.
X Mus. Coll. Surg., No. 204. Rokitansky, B. i. p. 2C2. Mr. Humphry has particularly
described this change in his Lectures, p. 142.
2S
434 oAaTiLAaiKODS tuhobs of thb bovbb. i
Of the cartilaginous tumors of the large long bones I need say little,
having drawn from them tho greater part of the general description.
Only, the relations of the growths, aceording to the part of the bone in
or near which they lie, may be worth notice.
When, then, the tumor grows at or about the articular end of a. Urge
long bone, it is almost wholly placed between the periostenm and Uie
bone. Here it usually surrounds the hone, but not with a nnifonn thick-
ness ; and the thin wall of the bone wastes and gradually disappears at
if it were eroded, or as if it changed its form, becoming canceUons, and
then growing into the tumor. I have never seen such a tumor en-
croaching on the articular surface of a bone. But it may grow up
all about the borders of the joint, and surround tliem. A strildiig
example of these relations of the
cartilaginous tnmor to the bone on
which it grows is in one of the
best and most characteristic ip^
cimens in the College Musenm ;*
a cartilaginons tumor of the hum^
rus, removed in an amptnation it
the shoulder-joint hj Mr. XiistoiL
His sketch of it is here copied.
The patient was a naval Burgen,
and the tumor had been growing
for nearly forty years. The mus
it now forms is nearly ten inches
across; it surrounds the upper thre«-
fourths of the shaft of the bomenu,
and nearly surmounts its articular
surface; and it shows abundant iso-
lated nodules, partial central ossifi-
cation and central softening, and
the growth of bone from tho cancel-
lous tissue of the hnmerus into the
tumor. It shows, too, very well,
how bloodvessels and nerves are
imbedded in the inequalities of such tumors without being involved by
them.
It is extremely rare, I think, for a cartilaginous tumor to grow within
the articular end, or in the medullary tissue near it, in a, large, long bone.
A striking specimen, however, was presented by Mr, Langston Parker to
Mr. Stanley, It was removed by amputation of the lower part of the
leg, from a young gentleman in whom it had grown slowly, and had dis-
• Mu», Coll. Surg, 779, Tha palient recovered from the operalion, but died two monlhf
■Oerwnidi with diieauof (he chest. The Bpecimen is r»pre*eated in Mi. loMon'* Praclicd
Sargery, p. 374, JTom wliich the sketch (Sg. 71) ia drawn.
OAETILAGIKOUS TUMORS OF THB BONBS. 485
tmctlj pulsated. The lower end of the fibula is expanded and wasted by
a growth of cartilage, mixed with a substance such as will be described
in the next lecture, as the characteristic material of fibro-plastic or mye-
loid tumors. The growth is rather larger than an egg, and is invested
by the remains of the expanded fibula, and by the periosteum ; and the
relations of the chief bloodvessels make it probable that the pulsation
felt daring life was derived from that of the vessels within the tumor.*
When a cartilaginous tumor grows at the middle of the shaft of a large,
long bone, it is, I think, usual to find coincidently both an external and
an internal growth. Cartilage lies outside the shaft, beneath the peri-
osteum; and another mass may fill the corresponding portion of the
medullary canal. Then, in the concurrent growth of the two masses, the
wall of the bone between them wastes or is broken up, and they may
form one great tumor set between the portions of the shaft.t These are
the cartilaginous tumors which most imitate the progress of malignant
disease. They are indeed very rare ; but the chance of the existence of
snch an one, where we might be anticipating a malignant tumor, is always
to be added to the motives for amputation in cases of tumors round the
shafts of these long bones.
When cartilaginous tumors grow at the attachment of tendons (and
they often do so, especially about the lower part of the femur), they are
peculiarly apt to acquire narrow bases of attachment. In these cases,
one usually finds a layer of cartilage incrusting some cancellous and
medullary bone, and the bone, as a narrow pedicle, extends into con-
tinuity with the wall or the cancellous tissue of the subjacent shaft.
Snch tumors have then the characters of polypoid outgrowths from the
bone, and may be treated accordingly ; for, when cut or broken off", their
stems (at least if they consist of only bone) will not grow. Indeed this
stem may chance to be unwittingly broken ; as in a tumor J removed by
Mr. Lawrence. It had grown on the inner and lower part of the femur,
and, when fairly exposed, was easily detached without further cutting :
the narrowest part of its stem rested in a slight depression in the femur,
but had no connexion by tissue with it. It seemed as if the narrow
pedicle of a tumor, two inches in diameter, had been by accident broken
off, and the friction of the broken surfaces had smoothed and fitted them
together.
* The specimen is in the Museum of St. Bartholomew's Hospital. No. 783 in the Mus.
G)1I. Surg, is an ossified cartilaginous tumor within the upper end of the fibula. In the
Moseum of St. Thomas's Hospital is a most remarkable instance of cartilaginous tumors
growing at once, in the scapula, the upper part of the humerus, and the lower part of the
same. In the last-named part the cartilage lies within the thinned walls of the bone. The
case is described by Mr. William Adams, in the Proc. of the Pathol. Soc., vol. ii.
Y A specimen of this form is in the Museum of St Bartholomew's in and upon a femur, in
Ser. i. No. Ill; and one of very largo size, around and in tlie upper third of the femur, is in
Guy's Hospital Museum. One also is mentioned by Mr. Hawkins as occurring in the middle
of the shaft of the humerus (Medical Gazette, vol. xxv. p. 476).
X Mus. St. Bartholomew's, Ser. i. 183.
486 OARTILAaiNOnS tumors of THB B0VB8.
Such are some of the chief facts to be noted about the cartilaginoitt
tumors on the large long bones.
On the jaws these tumors are, I believe, very rare. I know but one
specimen on the upper jaw alone ; a great tumor, portions of which are
preserved in the Museum of Guy's Hospital, and of which the history,
by Mr. Morgan, is in the Hospital Reports.
On the lower jaw, such tumors appear prone to acquire a peeuluii
shape, affecting the whole extent of the bone. One of the most remar|(-
able tumors in the Museum of the College* is of this kind. The patient
was a lady thirty-nine years oldi The tumor had been growing eight
years ; it commenced as a small hard tumor just below the first right
molar tooth, and gradually enlarged till it enclosed the whole jaw, except
its right ascending portion. It measured two feet in circmnference, and
six inches in depth, and the patient died exhausted by want of food,
which she was unable to swallow, and by the ulceration of parts of the
tumor during the last two years of her life.
M. Lebertf has recorded a case in which a tumor like this was removed
by Dieffenbach. In three successive operations he removed it by instal-
ments, and the patient finally recovered.
The cartilaginous tumors that grow about the cranial bones and the
vertebrae show, in a marked manner, that reckless mode of growth (if I
may so speak) which is more generally a characteristic of malignant
tumors. They grow in every direction ; pressing, and displacing, and
leading to the destruction of, important parts, and tracking their way
along even narrow channels.
In St. Bartholomew's is a tumor,J composed, for the most part, of
cartilage, which grew in connexion with the bones of the face and head
of a lad sixteen years old. It involved both superior maxillary bones,
extended into the left orbit, and through the left side of the base of the
skull into its cavity, compressing the anterior lobes of the cerebrum ; it
was also united to the soft palate, and protruded the left nostril, and
the integuments of the face.
The commencement of a similar growth is probably shown in a speci-
men in the College Mu8Cimi,§ in which, together with changes effected
by the growth of nasal polypi, one sees the ethmoid cells completely filled
with firm semitransparent cartilage, a mass of which projects in a
round tumor into the upper part of the left nasal fossa.
And here I may adduce, in proof of the tracking growth of the
cartilaginous tumors, the case of one|| originating in the heads of the
ribs, which extended through the intervertebral foramina into the
spinal canal, where, growing widely, and compressing the spinal cord,
• No. 1034 and 201. t Abhandlungen, p. 197.
X Mu8. St. Bartholomew's Hospital, Ser. xxxt. No. 47. Drawn in Mr. Stanley s Illustrationt
of Diseases of the Bones, pi. xvii. fig. 4. § Mus. Coll. Surg. 2199.
U Mus. St Bartholomew's Hospital, Ser. i. No. 115.
]
i
OABTIIiAaiNOUS TUMORS OK THE HANDS. 487
it produced complete paralysis of the pelvic organs and the lower extre-
mities.
The cartilaginous tumors of the hands deserve a special notice.
As manjy I believe, as forty cases might be collected from various
records, in which the bones of one or both hands, and sometimes of the
feet also, have been the seats of numerous cartilaginous tumors. Several
of these cases were collected by John Bell ;* many more by Muller,t
who drew, indeed, from these cases the greater part of his general
account of enchondroma ; and many more might now be added to the
Kst Four admirable specimens of the disease are in the Museums of the
College and of St. Bartholomew's.
The first of these,;( from the collection of Sir Astley Cooper, consists
of the amputated fingers and heads of the metacarpal bones of a girl
l^ years old. Tumors had been growing in these bones for^ eleven
yeirs ; and now there are eleven or twelve, from half an inch to an inch
and a half in diameter, and all formed of pure cartilage.
The second was presented to the Museum of St. Bartholomew's by
Mr. Hodgson. § It comprises the right hand, and the little finger of the
left hand, of a lad 14 years old, in whom, without any known cause, the
tomors had been growing from early childhood. In the right hand, the
metacarpal bone of the thumb contains two tumors ; that of the fore-
finger three or four tumors, of which the smallest is an inch, and the
largest is three inches in diameter : the first and second phalanges, also
of the forefinger, contain tumors ; the middle finger appears normal ;
the third finger has one tumor in its metacarpal bone, one in its first
phalanx, and two in its second phalanx ; the little finger has as many,
in corresponding positions. On the left hand the only tumor was that
in the first phalanx of the forefinger.
A third preparation|| contains the fore and little fingers removed by
Mr. Lawrence from a healthy lad seventeen years old. He had on his
left hand four, and on his right hand six tumors ; but those that were re-
moved were alone troublesome and increasing. They varied from one inch
and a half to one-third of an inch in diameter, were all covered with healthy
smooth skin, and appeared to grow from the interior of the bones. No
account could be given of their origin, except that they began to grow
when he was five years old ; and some grew more quickly than others.
In both fingers a formation of cartilage has occurred in the metacarpal
bones and the second phalanges, which was attended with scarcely any
■
• Principles of Surgery, vol. iii. p. 65.
t On Cancer. Whenever the statements made by Mailer respecting the general charac-
ters of cartilaginous tumors differ from the account here given, the ditferences may, I tliink,
be explained by ^is taking for the type the tumors of the hand. This alone could have
made him regard so little the ossification of cartilaginous tumors.
X Musw ColL Surg^ 775. § Described in the Pathological Appendix to the Catalogue.
I Mua. St Bartholomew's, Pathol. Appendix.
OABTILAOlnOUS TUU0B8 OH IHB BAVD8.
rif-Tl*
swelling : indeetl, till the operation was being performed, these bones
were not supposed to be the seats of disease, though their mednlluj
cavities were quite full of cartilage.
The fonrth spetnmea,
here eketched, is, I be-
liere, the most remark-
able yet seen. I reeeiTed
it from Mr. SahnoD, of
Wedmore. It is the rigkt
hand of a laborer, fiftj*
six years old, from whom,
when be was sixteen yean
old, the forefinger of the
left hand was remoTsd
with a tumor weighing
21b. 5oE. The little fin-
ger of the same hand hat
a tumor about as large u a
walnut : the whole length
of his left tibia has irre-
gular nodnlee od its ulte-
rior and inner snr&ce,
and some enlargement ex-
ists at his left second toe.
On the right hand, which Mr, Salmon amputated, there are tumors tm
every finger, and one spheroidal mass nearly six inches in diameter, in
which the second and third fingers appear completely buried, the wall*
of their phalanges being only just discernible at the borders of the mass
that has formed by the coalition of tumors that grew within them.
The disease which these specimcnB illustrate begins, I believe, exclu-
sively in the early period of life ; during childhood, or at least before
puberty, and sometimes even before birth. It occurs, also, much more
frequently in boys than in girls. One or more, or nearly all, of the
phalanges or metacarpal bones of one or both hands may enlarge slowly,
and without pain, into an oval, or round or heart-shaped swelling. When
such swellings are grouped, they produce strange distortions of the hands,
making them look like those of people who have accumulated gouty
deposits ; or, as John Bell delights to repeat, like the toes and claws of
sculptured griffins. They may greatly elongate the fingers, but they
more commonly press them asunder, limiting and hindering their move-
ments.
There is no rule or symmetry observed in the afiections of the hands.
except that the thumb is less frequently than the fingers the seat of growths,
Rnluced to oDO-fiAh of the
0ABTILAGIK0U6 TUMORS OK THE HANDS. 439
In the large majority of cases, if not in all, each tumor grows within
a bone, the walls of which are gradually extended and adapted to its
growth. And this position within the bones is the more remarkable, be-
cause, in the cases of ^gle cartilaginous tumors of the fingers or hands,
the growth takes place not more, but rather less, often within than with-
oat the bone ; these single tumors commonly growing, as those of the
larger long bones do, between the periosteum and shaft.*
Thus, growing within the bones, the cartilaginous tumors may be some-
times found, even in the same hand, in all stages of growth. One phalanx
or metacarpal bone may have its medullary cavity full of cartilage with-
out any external appearance of enlargement ; another may be slightly
BwoUen-ont at one part, or in its whole periphery ; another so extended
on one side, or uniformly, that its walls form only a thin shell around the
mus of cartilage ; in another the cartilage may have grown out through
holes absorbed in the walls of the bone, and may then have spread out on
its exterior ; while from another it may have protruded through apertures
even in the integuments, gradually thinned and ulcerated ;t or, as the
specimen sketched in fig. 72 shows, we may find not only siyh a pro-
trusion through integuments, but two originally distinct tumors, growing
oat beyond the limits of their respective bones, and coalescing in one huge
DASS. In cases of this kind, the cartilaginous mass in each bone usually
appears as a single tumor, with very delicate, if any, partitions. It may
have a coarsely granulated aspect, but it is rarely divided into distinct
nodules, or strongly intersected. Its exterior is adapted closely to the
interior of the shell or bone, but is not continuous with it, except by
bloodvessels. It rarely ossifies, except in a few small scattered cancellous
masses in its mid-substance.| And it is worth observing, that the tumors
often project on only one side of a bone ; for when this happens in the
metacarpus, it is often very hard to tell which of two adjacent metacarpal
bones should be cut out in case of need.
The cases of this singular disease have shown great diversity as to the
cause of the tumors, and in their modes and rates of growth ; some mak-
ing progress, some remaining stationary : and I believe it has often hap-
pened that at the time of manhood all have ceased to grow. But in regard
to all these questions, important as they are, we are yet in need of facts.
It wonld be easy, and as vain as easy, to speculate on the meaning of
such a disease as this. I believe no reasonable explanation of it can as
yet be given, unless it may be said that these are the results of an exube-
rant nutrition similar to that which in the embryo may produce supernu-
merary limbs, but is here more disorderly and less vigorous.
• Mas. ColL Surg. No. 772-3.
f A good case illustrating the last-mentioned fact is represented by Professor Miller, in his
Principles of Surgery, p. 179. The tumor on the back of the metacarpus weighed fourteen
pounds, and after protrusion bled frequently. John Bell also ha? recorded several such cases.
X Specimens of ossification are in the College Museum, No. 7850.
440 CARTILAGINOUS TUMORS OVBR THB PAROTID GLAKD.
The only remaining instances of cartilaginous tumors to which I shall
refer are those that grow near the parotid, or, much more rarely, neit
the submaxillary gland.* Some of these are formed of pure cartilage,
and might be taken as types of the cartilaginous tumor ; but more an
composed of cartilage, or fibrous cartilage, variously mixed with other
tissues, and especially with what appears to be an imperfect or a perverted
glandular tissue. Whichever of these forms they may have, they are
commonly imbedded in the gland. They are sometimes wholly surrounded
by the gland-substance, but much more commonly are more or lev
deeply imbedded in it, and covered with its fascia.
These tumor's are generally invested with tough fibro^ellular capsulei|
which, though sometimes loose, are more conmionly so closely attached
to the surrounding parts that it is difficult to dissect theiQ out. And the
inconvenience of this is not a little increased by the frequent contact of
branches of the facial nerve, which are apt to adhere very closely to the
deep part of the tumor, or to be imbedded between its lobes, or may evea
stretch over its surface.f
The general aspect of these tumors depends much on the proportion in
which the cartilage and their other component tissues are mixed. When
they are of pure cartilage, or when the cartilage, or delicately fibrous
cartilage, greatly predominates, they may present all the general charae-
tcrs that are abeady described. Such a case is illustrated by that to
which, among all the specimens of the kind, the primacy belongs. It
was removed by Mr. Hunter, and is enough to prove the skill and bold-
ness as an operator which some have denied him. The case was that of
a man, thirty-seven years old, who, sixteen years previously, fell and
bruised his cheek. Shortly after the injury, the part began to swell, and
the swelling regularly increased for four or five years, when he again fell
and struck the swelling, which, after this, extended especially at its lower
part and base. It seemed quite loose, and movable without pain. Mr.
Hunter extirpated it, and with complete success. It weighed 144 ounces,
and measures in its chief dimensions 9 inches by 7. It presents a strik*
ing instance of the conglomerate cartilaginous tumor, consisting of nume-
rous round masses of pale, semi-transparent, glistening cartilage, con-
nected by their several fibro-cellular investments; and its exterior is
deeply lobed and nodulated. Its apparent composition is confirmed by
the microscopic examinations of Mr. Quekett,| who found it composed
• These are grouped by Rokitansky as the third variety of the Gelatinous Sarcoma, with
a recognition of their affinity to Enchondromn. Mr. Syme names them " Fibro-cartilaginoos
Sarcoma " (Principles of Surgery, voL i. p. 89). The first good description of them was
given by Mr. Lawrence (in his pap Tumors, already often quoted). Mr. Cspsar Haw-
kins described them, for the most part, as '' conglomerate tumors."
t Tlie imbedding of important parts in a cartilaginous tumor need be remembered. In
the Aluseum of St. George's Hospital is a specimen of this kind, about seven inches in dia-
meter, which was sent to the Museum with the history, that, in removing it from the deep
tissues of the thigh, the femoral artery was cut across where passing through its substmnce.
f Histological Catalogue, vol. i. p. 111. Ag. 52.
CABTILAOIirOUB TUHOBS OVKB THE PAKOTID OLAKD. 441
of ouiilage, in whicli some of the intflrcellular Biibst&nce is homogeneous,
wd some finely fibrous.
Bat when in these tnmora the carti- "■- '^*
l^e is equalled or exceeded in quantitT'
by the oUker tissue of which they may
eonsist, we may find the same oval and
nodular or lobed form, and the same
hardness or firmness and elasticity, but
they appear, on section, opaque white
or cream-colored, and less glistening
than cartilage-t Generally, these
mixed tumors appear uniform ; but,
■ometimes, portions of purer cartilage
are imbedded iu the mixed tissue, and
olncDrely bounded from it.|
In microscopic characters the carti-
laginons parts of these tumors has, I
beliere, no peculiarity ; different speci-
UKtB may ofier all the variety of forms
tOThicb I hare already referred.
The tissue mixed with the oartila-
pmoB is at present. I think, of un-
certain nature. In five cases I have
found it, for the most part, present
I lobed and clustered structure, with fibrouB-lookiug tissue encircling
spaces that are filled with nuclei and cells. These enclosed spaces look
■0 like the acini of a conglomerate gland, that they seem to confirm the
(pinion one might form from its general aspect ; namely, that it is an
imitation of gland-tissue. And this is confirmed by the character of the
cells within the seeming acini ; for they have the general traits of gland-
cells. They are usually email, round or oval, flattened, dimly granular,
with nearly round, pellucid nuclei with nucleoli. They lie either like a
thin epithelial lining of the spaces I just mentioned, or else they are
clustered within them ; or they may be irregularly grouped through the
whole substance of the tumor ; and in all cases abundant free nuclei like
their own are mingled with them.
•Fig. 73. Minute giruciure* of b mixed cnnilaginoi is tumor over tlie parotid gland. In ihe
upper Bketcb, s group or withered, ulellnle, cartilapi? nui^lci nre encircled witli fibrous tissue
Olhen lis neai the group ; while, equallj' near, are well-formed eartilageK:ellB, anil groiipi.
otimall nuclei or tmclealsd cells, like IhOBe of gland atruoIuiBB. In Ibe towei alieich liinilar
coipiuclea are grouped as in Ihe acious of a gland.
I Tbey are among the tumors which one finds described as like lumipii or like potatoes.
} T bave oflen endesTtiTed to see whence this mixture of (issues results, nnri esptciallf
whether the one tissue is transformed into Ihe other ; but I have not been able to discover
ibia. Ti may be that diese tumors are, in the first instance, composed wholly of one of [he
iiro pritKipal tissues, and that in their further growth this primary tissue is superseded by
ibe olber. But it is, perhaps, more probable thai in an apparently unifarm blastema, two
M more diflerent stractares ihoald be dereloped, and thencefaiwaid ocnncideatli %tow.
442 BEOUBRSKT CARTILAGINOUS TUMORS.
Such are the most general characters of these cells ; bat they are apt
to vary from them, being more angular, or bearing processes, or bdng
attenuated or caudate. Even if we may consider them as imitating
gland-structures, yet it may be a question whether they are related to
the adjacent parotid gland, or to lymphatic gland. It would be easy to
discriminate between the elements of the parotid and of a lymphatic in
their natural state ; but a morbid imitation of either of them may deviate
far enough to be as much like the other. And it is well to remember
that these tumors have exactly the seats of naturally existing lymphatie
glands, and are often closely imitated by mere enlargements of these
glands ; so that, possibly, future researches may prove that they are
cartilaginous tumors growing in and with a lymphatic gland over or
within the parotid or submaxillary gland.
In general history, especially in their slow and painless growth, the
absence of any morbid influence, except that produced by pressure, (m
the surrounding parts, the absence of proneness to foul ulceration, and
of tendency to return after removal ; in all these, the tumors over the
parotid agree, I believe, with the other forms of cartilaginous tumors. I
will therefore not delay to relate cases of them ; but will draw towards
conclusion by referring to some points connected with the general histoij
and nature of the whole group of cartilaginous tumors.
First, then, concerning their origin : — They begin, in a large majority
of cases, in early life ; between childhood and puberty. Yet they may
begin late in life. I saw one on the hand, which had been of no long
duration when it was removed from a man 70 years old ; another, grow-
ing in the humerus, and described by Mr. W. Adams,* had grown
quickly in a man of 61 ; another began to grow at the same age, in a
woman's thumb.f Most commonly, also, those in or near the parotid
appear in or after middle age.
Then, concerning their nature : they may be regarded as, usually,
completely innocent tumors, and yet there are some cases recorded, in
which we must believe that, after a cartilaginous tumor has been removed,
another has grown in the same place. I saw one such in a woman 30
years old, in whom, soon after the removal of one tumor &om the parotid
region, another grew and acquired a great size. This was an unmixed
cartilaginous tumor; and I believe the first was of the same nature.
Dr. Hughes BennettJ has related a case in which Mr. Syme removed a
cartilaginous tumor of the arm by amputation at the shoulder-joint.
Subsequently, the patient, a girl 14 years old, died with tumors in the
stump and axilla. Mr. Liston removed a portion of the scapula, with a
great tumor in its spine and acromion, which I have no doubt is a soft
cartilaginous tumor. § Three years afterwards the patient died, with
* Proceedings of the Pathological Society, ii. 344. f Lebert; Abhandlungen, p. 191.
J On Cuieerous and Cancroid Growths, pp. 108 and 258. § CoUege Museum, No. 781.
MIXBB CABTILAGIKOUS TUMORS. 443
what is described as a return of the disease. Mr. Fergnsson showed at
the Pathological Society a fibro-cartilaginous tumor* of the lower jaw,
nhich had grown twice after the complete removal of similar tumors from
the same part. In the Museum at Guy's Hospital, also, there is a carti-
laginoos tumor growing from the angle of the lower jaw into the mouth,
which is said to have grown after complete removal of a similar tumor
with the portion of lower jaw to which it was connected. Lastly,
Professor Glugef records two cases in which we must believe that recur-
rence of cartilaginous tumors ensued after complete removal. In one, a
ctrtilaginous tumor, of 18 years' growth, and 9| pounds weight, over a
man's scapula, clavicle, and neck, returned in the ribs, and destroyed life
in a year and a half. In another, a similar tumor of the orbit returned
two and a half years after removal.
We must conclude, I think, from these cases, that, although the general
rde of innocence of cartilaginous tumors is established by their usual
history, by numerous instances of permanent health after removal, and
by cases in which, after death, no similar growths are found in lymphatics
or internal organs, yet recurrence after operations may ensue. I think
that when this happens it will generally be found that the recurring
growths, if not the original growths also, are soft, rapid in their increase,
and apt to protrude and destroy adjacent parts ; as if we had, again, in
these, an instance of that gradual approximation to completely malignant
characters, of which I spoke in the twenty-first lecture. I think, too, that we
shall find that these soft cartilaginous tumors which are apt to recur, or
of which more than one exist in difierent parts on the same patient, afi*ect
ptrticularly those who are members of cancerous families (see p. 431).
In connexion with these points I may refer to some additional facts in
the pathology of cartilaginous tumors.
First, many may exist in the same person ; secondly, they are some-
times hereditary ; thirdly, they are not unfrequently mingled with can-
cerous growths.
Multiplicity is sufficiently marked in the cases of the hands and feet,
but has been observed, though more rarely, in other parts ; as in a case
recorded by Mr. William Adams, and already referred to, as presenting
tumors at once in the scapula and parts of the humerus. The case by
Mr. Bickersteth (p. 431) was probably of the same kind.
The hereditary occurrence was observed in the case of a cartilaginous
tumor of the pelvis, of which I have already spoken, as examined by Mr.
Donald Dalrymple. The patient's father had a large ossified enchon-
droma of the radius, which was removed by Mr. Martincau.J
* Mr. Simon examined it with the microscope, and found it formed of well-marked carti-
lage, with a fibrous basis.
t Atlas der pathologischen Anatomie, Lief. iv. ; and Pathologische Histologic, p. G7.
{ The specimens ore in the Museum of the Norfolk and Norwich Hospital. In the num-
ber of the Edinburgh Monthly Journal, vol. xiii. p. 195, an abstract of the ca.<e is published
by Dr. Cobbold, who relates, in addition to the facts I had learnt from Mr. lliomas Cresse,
*. I--
444 MIXED OABTILAGINOUS TUMORS.
The conjunction of cartilaginous and medullary cancerous tumora,
may, perhaps, be called frequent, especially in the testicle.
A man, 38 years old, was under Mr. Lawrence's care with an appiieat
enlargement of one testicle, which he ascribed to a blow received eighteen
months previously. Three weeks after the blow he noticed an enlarge-
ment which regularly increased, and formed an' oval mass about four
inches long. This, at it« upper part, was moderately firm and elastic;
but in the lower third it felt incompressibly hard. It was removed, and
proved to be a pale, soft, grayish, medullary cancer in the testicle, having
in its lower part a mass of cartilage, with scattered points of bone, and
some intercellular tissue.* The patient died a fortnight after the ope-
ration ; and it was interesting to observe, as illustrating the contrast be>
tween the cartilaginous and the cancerous growths, that he had soft
medullary cancerous tumors in the situation of his lumbar lymphatie
glands, but no cartilaginous tissue in or mingled with them.
A specimen closely resembling this, and with a very similar history, if
in the Museum of the University of Cambridge. Another is in ths
Museum of Guy's Hospital, of which it is said that the patient died with
return of the medullary disease. Miillcr noticed the same combination.t
Yirchowt has cited two cases and described one, all illustrating the same
singular fact. In the three specimens that I have seen of conjunction of
cartilaginous and medullary growths in the testicle, the cartilage appears
as an isolated mass in the substance of the medullary tumor, and is en-
closed in a distinct capsule. There are cases, however, in which the two
morbid substances, though distinct, yet lie in so close contact that they
are confused with one another. Thus, in a tumor which, as already men-
tioned (p. 429), was attached to the front of the lumbar vertebrae, and
weighed thirteen pounds, half was formed of soft flocculent medullary
cancer, and half of nodules of cartilage, some with soft, some with os-
seous centres.§ A tumor removed from over a woman's parotid gland by
Mr. Lloyd, was invested by a single fibro-cellular capsule ; but one half
was cartilaginous and the other looked like medullary substance, and they
were mingled, with no distinct boundary line, at their contiguous borders.|I
And lastly, in a case of which preparations are in the Museum of St
Thomas's Hospital, Mr. Dodd removed a genuine and apparently un-
mixed cartilaginous tumor from a man's ribs; but, in three months,
that a brother of the man who had the tumor in the pelvis, has mollities ossium, and that
" others of his kindred had been subjected to the debilitating influences of a perverted mh
trition."
* The specimens and drawings are in the Museum of St Bartholomew's.
t On Cancer.
J Verhandl. der phys.-med. Gesellschaft in WQrzburg,'i. p. 134. Baring (Ueber den
Markschwamm der Hoden, PI. ii.) has represented a similar specimen.
§ Mus. Coll. Surg. 207 j Mus. St Bartholomew's, Ser. xxxv. No. 49.
11 Mus. Coll. Surg. 207 a ; Mus. St. Bartholomew's, Ser. xxxy. No. 45. The patient was
alive at least seven years aAer the removal of the tumor.
]
-i
I
MIXBD CARTILAGINOUS TUMORS. 445
another tumor appeared in the same part, formed of closely mingled car-
tilage and medullary substance. This quickly proved fatal.
I need hardly remark on the bearing which this last case may have on
the question of the recurrence of cartilaginous tumors, and on that of
the changes of character which may ensue in tumors generally, at their
saccessive occasions of recurrence. It gives to all these cases a much
higher interest than would attach to them if regarded only as rarities
and strange things.
But it is not with the malignant diseases alone that cartilage is found
in tumors. I have described it as combined with what appears like glan-
dular tissue in the tumors over the parotid, and I have seen bone in similar
combination in a tumor in the lip. Specimens are not rare in which closely
grouped nodules, and irregular masses of pure white cartilage are im-
bedded in jBbro-cystic tumors in the testicle. In speaking of the fibro-
cellular tumors, I mentioned two in which cartilage was similarly mingled
with their more essential constituent ; and in the Museum of Guy's Hos-
pital is a tumor removed from beneath the gastrocnemius muscle, which
consists of both fibro-cellular and adipose tissue, with abundant imbedded
nodules of cartilage. And lastly, similar combinations appear to exist
of cartilaginous growths with those which M. Lebert named fibro-plastic,
and which will be described in the next lecture as myeloid tumors. Such
18, 1 believe, the composition of three tumors in the Museum of St. Bar-
tliolomew's— of which one surrounds the head of the tibia ;* another in-
Tolves the bones of the face, and extends into the cranium ;t and a third
occupies and expands the lower end of the fibula.| The compound
Btacture of the last was ascertained with the microscope, which easily
detected the two materials irregularly mingled in every part of the tumor.
In all these facts concerning its combination with other morbidly pro-
duced structures, there must be something of much importance in rela-
tion to the physiology of cartilage ; but as yet, I believe, we cannot
comprehend it. Such combinations are not, I believe, imitated in the
cases of any other structures found in tumors ; even those that are thus
combined with cartilage do not, I think, combine with one another, if we
except the cases of intra-uterine morbid growths. As yet, however, the
interest that belongs to all these injuries is scarcely more than the inte-
rest of mystery, and of promise to future investigators. As yet, we can
think scarcely more than that, as innocent tumors, generally, are remote
imitations of the abnormal excesses of development which occur in em-
bryo-life, so it might be expected that, in some of them, many of the
tissues would be combined in disorder, which, orderly arranged, make up
the foetus.
* Series i. 41 ; and Mr. Stanley's Illustrations, PI. 15, fig. 3.
t Ser. XXXV. 47 ; and the same Illustr., pi. 13, fig. 4.
:|: Appendix to Pathol. Catal.
446 MTfiLOIB TUMORS.
LECTURE XXVIIL
PART I.
MYELOID TUMORS.
The Tumors for which I venture to propose the name of Mj
[jwtXtitdTjq^ marrow-like), were first distinguished as a separate kin
M. Lebert.* Before his discovery of their minute structure, they
confounded with fibrous tumors, or included among the examid
sarcoma, and especially of osteo-sarcoma. M. Lebert gave diet
name of '^fibro-plastic,'' having regard to their containing coriM
like the elongated cells, or fibro-cells, which he has called by the
name, and to which I have so often referred as occurring in the
mental fibro-cellular and fibrous tumors, and in developing lympl
granulations. But the more characteristic constituents of these to
and those which more certainly indicate their structural homology
their likeness to natural parts) are peculiar many-nucleated corpm
which have been recognised by KoUikerf and Robin| as constitaei
the marrow and diploe of bones, especially in the foetus, and in
life. It seems best, therefore, to name the tumors after this
nearest affinity. On similar grounds, they must be regarded as hai
nearer relation to the cartilaginous than to the fibrous tumors ; for
essential structures, both the many-nucleated corpuscles and the
gated cells, are (like those of cartilaginous tumors) identical with n^
rudimental bone-textures. Moreover, as I have already said, poi
of myeloid structure arc sometimes mixed with those of cartilaj
tumors, and they are sometimes developed into naturally constr
cancellous and medullary bone. The structures of this group of ti
are, indeed, essentially similar to those found in granulations which
from, and may be transformed into, bone (see page 128) ; and
section of such granulations some specimens bear, even to the on
eye, no small resemblance.
The myeloid tumors may be found in many situations ; but the;
far more frequent in or upon the bones than in connexion with any
tissue. I have seen them in the mammary gland, and I think i
neck, near the thyroid gland; and M. Lebert mentions many
parts as occasionally containing them, especially the eyelids and
junctivse, the subcutaneous tissue, the cerebral membranes, anc
uterus.§
* Physiologie patbologique, ii. p. 120 ; and Abhandlungcn, p. 123.
t Mikrosk. Anatomie, B. ii. p. 364, 378,
^ Comptes Rendus. . . . de la Socidt6 de Biologie, T. i. p. 150} T.ii. p. 8, and Mei
p. 143.
$ L. c; and in Yiichow and ReinhacVs Archiv^B. iii. p. 463. But I think that in i
r
STBUCTUBB OV MYELOID TUMORS. 447
As usually occurring in connexion with the bones, a myeloid, like a
fibrous tumor, may be either enclosed in a bone whose walls are expanded
round it, or, more rarely, it is closely set on the surface of a bone, con^
insed with its periosteum. The sketches in p. 105, of fibrous tumors
within and upon the lower jaw, might be repeated here for myeloid tumors ;
and the two kinds are about equally common in the same positions, both
within and upon tfie upper jaw. When enclosed in bone, the myeloid
tumors usually tend to the spherical or ovoid shape, and are well defined,
if not invested with distinct thin capsules ; seated on bone, they are, as
in epulis of this structure may exemplify, much less defined, less regular
in shape, and often deeply lobed. They feel like uniformly compact
masses, but are, in difierent instances, variously consistent. The most
characteristic examples are firm ; and (if by the name we may imply
neh a character as that of the muscular substance of a mammalian
heart) they may be called " fleshy." Others are softer, in several gra-
dations to the softness of size-gelatine, or that of a section of granula-
tions. Even the firmer are brittle, easily crushed or broken ; they are
not tough, nor very elastic, like the fibro-cellular or fibrous tumors ;
neither are they grumous or pulpy ; neither do they show a granular or
fibrous structure on their cut or broken surfaces.
On section, the cut surfaces appear smooth, uniform, compact, shining,
nocnlent with a yellowish, not a creamy, fluid. A peculiar appearance
is commonly given to these tumors by the cut surface presenting blotches
of dark or livid crimson, or of a brownish or a brighter blood-color, or
of a pale pink, or of all these tints mingled, on the grayish-white or
greenish basis-color.* This is the character by which, I think, they
may best be recognised with the naked eye, though there are diversities
10 the extent, and even in the existence, of the blotching. The tumor
may be all pale, or have only a few points of ruddy blotching, or the
cut surface may be nearly all suffused, or even the whole substance may
have a dull Modena or crimson tinge, like the ruddy color of a heart, or
that of the parenchyma of a spleen.f
Many varieties of aspect may thus be observed in myeloid tumors ;
and, beyond these, they may be even so changed that the microscope
may be essential to their diagnosis. Often, they partially ossify ; well-
of these instances he has included in his account tumors containing only the elongated
" fibro-plastic^' cells ; whereas I have reckoned, as belonging to this myeloid group of tumors,
none but those which, together with such cells, contained also the large many-nucleated
ooxpuscles, which alone are a peculiar constituent. A tumor containing elongated fibro-
cells alone, I should expect to be a rudimental fibro-cellular, or fibrous, or recurring fibroid
tumor. They may, also, appear as a chief constituent in tumors containing abundant in-
flammatory exudation.
* Lebert says the greenish-yellow color that they may show depends on a peculiar sort
of fat, which he calls Xanthose (Abhandl. 127).
1 1 believe that many of what have been named spleen-like tumors of the jaw have been
of this kind. Tlie color they present is not due only to blood in them ; more of it is appro-
priate to their texture, as that of the spleen is, or that of granulations : and it may be quickly
and completely bleached with alcohol.
448 STBUOTUBB OF MTBLOID T1TM0B8.
formed, cancellous bone being developed in them. Cysts, also, filled
with bloody or serous fluids, may be formed in them, occupying much of
their volume, or even almost excluding the solid texture. In the lut
case the recognition of the disease is very difficult. I lately amputated
the leg of a woman, 24 years old, for what I supposed to be a cancerous
tumor growing within the head of the tibia. She had had pain in this
part for eighteen months, and increasing swelling for ten months ; and
it was plain that the bone was expanded and wasted around some soft
growth within it. On section, after removal, the head of the tibia, in-
cluding its articular surface, appeared expanded into a rounded cyst or
sac, about 3} inches in diameter, the walls of which were formed by thin
flexible bone and periosteum, and by the articular cartilages above.
Within, there was little more than a few bands or columns of bone^
among a disorderly collection of cysts fiUed with blood or blood-colored
serous fluids. The walls of' most of the cysts were thin and pellucid;
those of some were thicker, soft, and brownish-yellow, like the substanee
of some medullary cancers ; a likeness to which was yet more marked in
a small solid portion of tumor, which, though very firm, and looking
fibrous, was pure white and brain-like.
None who examined this disease with the naked eye alone felt my
doubt that it was an example of medullary cancer, with cysts abundantly
formed in it. But, on minuter investigation, none but the elements
which I shall presently describe as characteristic of the myeloid tumon
could be found in it : these, copiously imbedded in a dimly granular sub-
stance, appeared to form the substance of the cyst-walls, and of whatever
solid material existed between them. The white brain-like mass was,
apparently, composed of similar elements in an advanced fatty degene-
ration ; neither in it, nor in any other part, could I find a semblance of
cancer-cells.
I have not seen another specimen deviating so far from the usual
characters of myeloid tumors as this did ; but I think that, as in this, ao
in any other variation of general aspect, the microscopic structures would
suffice for diagnosis ; for there is no other morbid growth, so far as I
know, in wliich they are imitated. They consist essentially of cells and
other corpuscles, of which the following are the chief forms : —
1. Cells of oval, lanceolate, or angular shapes, or elongated and
attenuated like fibro-cells or caudate cells, having dimly dotted contents
with single nuclei and nucleoli (fig. 74, a).
2. Free nuclei, such as may have escaped from the cells ; and, among
these, some that appear enlarged and elliptical, or variously angular, or
are elongated towards the same shapes as the lanceolate and caudate
cells, and seem as if they were assuming the characters of cells.
3. The most peculiar, form; — ^large, round, oval or flask-shaped, or
irregular cells and cell-like masses, or thin disks, of clear or dimly gra-
nular substance, measuring from ^io to uhji of an inch in diameter, and
BIBTOBT or HTILOID TCHOBS. 449
eonWnisg from two to tea or more oval, clear, and nncleolated naclei
(% 74, B : see also fig. 76, p. 453).
Corpuscles soch as these, irregularly aod in diverse proportions im-
liedded in a dimly granular substance, make up the mass of a myeloid
tomor. They may be mingled with molccul&r fatty matter ; or, the mass
they compose may be traversed with filaments, or with bundles of fibro-
cellular tissue and bloodvessels: but their eEsential features (and
especially those of the many-nucleated corpuscles) are rarely obscured.
Respecting the general history of the myeloid tumors, the cases
Mtlierto minutely observed are too few and too various to justify many
general conclusions. Not that the disease is a rare one : for there can
be little doubt that many cases recorded as e:(ampleB of epulis, of fibrous
tttmora of the jawa, of osteo-sarcoma, and even of cancerous growths
■bout the bones, should be referred to this (rroup. At present, however,
I can refer to no cases but those by M. Lcbert, and those which I have
myself been able to observe. From these, the moat general facta I can
collect are, that the myeloid tumors usually occur singly ; that they are
most frequent in youth, and very rare after middle age ; that they gene-
rally grow slowly and without pain ; and generally commence without
any known cause, such as injury or hereditary disposition. They rarely,
except in portions, become osseous ; they have no proneness to ulcerate
or protrude ; they seem to bear even considerable injury without becom-
ing exuberant ; they may (but I suppose they very rarely) shrink, or
cease to grow ; they are not apt to recur after complete removal ; nor
have they, in general, any features of malignant disease.
I may illustrate these general statements by abstracts of some of the
cases I have recorded ; selecting for the purpose those which were, on
Miy ground, the more remarkable-t
A lad, eighteen years old, was under Mr. Stanley's care, between five
uid six years ago, with a tumor occupying the interior of the symphysis,
* Tig. 74. MicKMOopic ■truclures of mjelotd tumoii. A, elongated cell), or fibio-pln^tlo
celli (Leben). a, a clusiet of many-nuclraled ceKi. Magnifled aboul 350 tiniei.
t Tlie apeciineDS obouned &om all (he following casea are in ibe Mukuth of Si. Bar-
tboknww'i.
450 HISTOBY OF MYELOID TUMOB&
and immediately adjacent parts, of his lower jaw-bone. It had be^
observed gradually increasing for eight months without pain, and in its
growth had disparted the walls of the jaw, hollowing out a cavity for
itself, and projecting into the mouth through one of the alveolL Mr.
Stanley removed the portion of the jaw, from the first left true molar to
the first right premolar tooth. The tumor presented the greenish and
grayish basis, blotched with crimson and various brownish tints, and the
characters of firmness, succulency, and microscopic texture, which I have
described as most distinctive of the myeloid tumors. It was the specimen
from which some of the microscopic sketches were made, and might be
considered typical. This patient is still in good health, with no appear-
ance of return of the disease.
Mr. Lawrence had under his care a woman, twenty-one years old,
with a tumor in the alveolar part of the front of the upper jaw. This
was of about twelve months duration, and had sometimes been veiy
painful. It was seated in the cancellous tissue between the walls of tiM
alveolar and adjacent portion of the upper jaw, projecting slightly into
both the mouth and the cavity of the nose, and raising their muoouB
membranes after passing through the wasted bone. After catting away
the front wall of the jaw, the tumor was cleared out from all the cavity
in which it lay imbedded. It was in all microscopic characters like
that last mentioned, and resembled it in general features, except in that
it had in every part the dark ruddy color of a strong heart. He opera-
tion was performed two years ago, and there has been no reappearance
of the disease, such as would have occurred in the case of a malignant
tumor, if an attempt had been- made to remove it without the bone in
which it was growing.
A woman, 22 years old, was under Mr. Lawrence's care, in March,
1851, from the alveolar part of whose right jaw, growths which were
regarded as examples of epulis had been four times removed in the pre-
vious thirteen months. In the operation in August, 1850, the growth
was found to extend through the socket of the first molar tooth into
the antrum, or into a ca\ity in the jaw. It was wholly removed (as it
was thought), and the wounds healed soundly ; but nine weeks afterwards
a fresh growth appeared, that seemed to involve or arise from nearly the
whole front surface of the right upper jaw-bone : it was firm, tense, and
elastic, but not painful, projecting far on the face, as well as into the
nostril, and into the cavity of the mouth at both the gum and the hard
palate. This swelling, under various treatment, rapidly increased ; and
in December, 1850, a similar swelling appeared at the left canine fossa,
and grew at the same rate with that of earlier origin. Of course the
coexistence of two such swellings led to the fear, and in some minds to
the conviction, that the disease was cancerous ; and the more, because,
at nearly the same time with the second of these, two soft tumors had
appeared on the parietal bones. Still, the patients general health was
HISTORY OF MTELOID TUMORS. 451
bnt little impaired ; and vrhen the mucous membrane of the hard palate
nlceratcd over the most prominent parts of the tumors, neither of them
protruded, or bled, or grew more rapidlj.
In April, 1851, the growth of the tumors appeared to be very much re-
tarded, and for the next month was hardly perceptible ; and the patient
being very urgent that something should be done to diminish the horrible
deformity of her face, Mr. Lawrence, in May, cut away the greater part
of the front and of the palatine and lower nasal parts of the right upper
jaw, and removed from the antrum all that appeared morbid, including,
doubtless, nearly every portion of the tumor.
The excised portion of the jaw-bone was involved and imbedded in a
large, irregularly spherical tumor, composed of a close-textured, shining,
soft, and brittle substance, of dark grayish hue, suffused and blotched
with various shades of pink and deep crimson. It was not lobed, but
included portions of cancellous bone, apparently new-formed, and was
Tery closely adherent to all the surrounding parts. To the microscope
it exhibited all the characters that I have described above ; and the
miny-nucleated corpuscles were remarkably well defined and full. They
eomposed nine-tenths of the mass, and were arranged like clustered cells.
The patient perfectly recovered from the effects of the operation ; and,
to every one's surprise, the tumor on the left upper jaw, which had been
in all respects like that removed from the right side, gradually disappeared.
It underwent no apparent change of texture, but simply subsided. The
swellings on the parietal bones, also, the nature of which was not ascer-
tained, cleared away ; and when the patient was last seen, a few months
ago, she appeared completely well, and no swelling could be observed.
No case could better show than this did the conformity of the myeloid
tumors with the general characters of innocent growths : on the other
band, the following might well have been regarded as a malignant dis-
ease, if its structure and limitation to a single part had not been con-
sidered.
A fanner's boy, 15 years old, was under Mr. Stanley's care, in the
winter of 1851, with a large tumor covering the upper part of his head,
rising to a height of from one to two inches above the skull, extending
nearly from ear to ear, and from the occipital spine to the coronal suture.
This had been in progress of constant growth for three years, and was
believed to have originated in the effects of repeated blows on the head.
The head now measured 21 inches in circumference, and 16^ inches over
its transverse arch. Just before his admission he had become blind in
one eye, and nearly so in the other ; his gait was unsteady ; he had
severe pains in and about the forehead, but his intellect was not affected,
and he appeared in good general health. The scalp over the tumor was
exceedingly tense, and, at the most prominent part, rather deeply ulce-
rated. The temporal and occipital arteries were very large and tortuous :
theN^orresponding veins felt like large sinuses.
452
UISTORY OF MYELOID TUMOBB.
Id the last two months of hia life, while in the hospital, his hlindDeu
became complete ; he lost nearlj all power of hearing, and suffered severf
paroxysms of headache. A large portion of the scalp and of the svi^^
cent tumor sloughed, leaving a great suppurating cavity, in the etiil
growing tumor. At length, two days before death, convulsions enwed,
which were followed by coma ; mid id this he died.
^)f^
The tumor covered all the surface of the skull, in the extent above
mentioned, rising gradually from its circumference to a height of two
inches at and about its central parts. A similar growth of somewhit
less dimensions existed within the corresponding parts of the interior of
the skull, included the dura mater and longitudinal sinus, and decpk
impressed the cerebrum. And, again, material similar to that forming
these growths was infiltrated in and expanded the included parts of the
bones of the vault of the skull. From both surfaces of these bones
osseous spicida and thin lamellse extended into the bases of tho corre-
sponding parts of the tumor. The adjacent sketch (fig. 76), from thfl
preparation in the Museum of St. Bartholomew's, shows the relatiooa
of this singular growth to the skull and brain, as seen in a. transveiM
The extra-cranial portion of the tumor had a nearly uniform dense and
elastic texture, of dull yellow color, mingled with while. Its cut surfaoo
appeared smooth, without distinct fibrous or other structure, and to th* ,
unaided eye looked like tho firmest medullary cancer, involving tho peri-
cranium, and partially exposed by ulceration of the scalp. The intn-
cranial portion was soft, easily crushed and broken into pulp, parpl^
streaked with pale gray and pink tints. It looked obscurely fibrotis, and
was intersected by shining bands derived from the dura mater and falx
involved in it. To the naked eye it was like a softer medullary tumor,
and was closely connected with the impressed surface of the brain, la
the substance of which, Just beneath it, was a largo abscesa.
HISTORY OF MTELOID TUM0K8.
458
Different, however, as the two parts of the tumor appeared, there was no
eorresponding difference in their microscopic elements: these were essen-
tially the same in both parts ; and though the tumor was so like cancer
in its general aspect, jet its minute structures were not cancerous. They
were chiefly as follows: — (1) Begular, oval, and well-defined cells, about
3)9 of an inch in diameter, containing dimly-granular or dotted sub-
stance, in which many oval nucleolated nuclei were imbedded (fig. 76, a).
They cerresponded exactly with the corpuscles characteristic of the mye-
loid tumors ; but they had more distinct cell-walls than I have seen in
my other case, and some had even double contours, as if with very thick
eeU-walls. (2) Irregular masses or fragments, of various sizes and
shapes, having the same apparent substance as the contents of the cells,
md containing similar numerous imbedded nuclei, but no defined cell-
walls (fig. 76, b). In these also, the identity with the constituents of
myeloid tumors was evident. (3) More abundant than either of these
fonns were bodies like the many-nucleated cells, but having on their
iralls, as it were wrapped over them, one or more elongated caudate nu-
cleated cells (c). They seemed to be formed like the peculiar corpuscles
m epithelial cancers, in which one finds cells or clusters of nuclei invested
with layers of epithelial scales concentrically wrapped roimd them. Their
borders presented two or three concentric lines, as if laminated ; between
these were one or more nuclei ; and often the innermost of the lines was
htyed inwards towards the cell-cavity, leaving a space in which a nucleus
was lodged. Sometimes, from the circumference of such bodies, one
could find curved nucleated elongated cells dislodged (d).
Fig. 7«.«
B
In most instances these laminated cells were filled with the dimly
granular substance and the many nuclei ; but in some there were clear
spaces, that seemed to contain only pellucid liquid. The elongated cells
that could be sometimes detached from these laminated cells agreed, in
general characters, with the remaining principal constituent of the growth ;
namely, (4) narrow, long, caudate, and fusiform cells with out-swellmg
nuclei, like those of developing granulations, and such as I have de-
scribed as constant elements of the myeloid tumors.
All the minute structures just described were found closely compacted,
and making, with free nuclei and granular matter, up the mass of both
• Fig. 76. Microscopic elements of the myeloid tumor of the skull, described in the text.
Jdagnified 350 times.
464 HISTORY OF MYELOID TUMORS.
portions of the tumor ; and the only apparent difference was, that, in \^
the intra-cranial portion, they appeared more generally to contain gr»- ji
nules, and to be mixed with granule-cells and granule-masses, as if this b
part of the tumor were more degenerate than the other.
I fear that even so abbreviated a record of this case as I have ven-
tured to print may seem very tedious; but it is not for its own rarity
alone that the case is important. It would be difficult to find a tumor
more imitative of cancer than this was in its mode of growth, its infil-
tration of various tissues, its involving of important parts, its apparent
dissimilarity from any natural structures. And yet it certainly was not
cancer; the microscopic elements were like those of natural parts: not a
lymphatic or any other organ was affected by similar disease, and death
seemed to be due solely to the local effects of the growth.
But while these, and many other cases, may be enough to prove thift
the myeloid tumors are generally of innocent nature, yet I suspect
may be found in which, with the same apparent structures, a malij
course is run. Of such suspicious cases, the two following are examples:—
A woman, 50 years old, was under Mr. Stanley's care, in 184T, with
an irregular, roundish, heavy tumor, between two and three inches in
diameter, in her left breast. It projected in the breast, and the skin
over it was red and tense, and at one part seemed to point, as if with
suppuration. Some axillary glands were enlarged, but not hardened.
This tumor had existed about nine months, had been the seat of
occasional pain, and was increasing. It was considered to be hard canc^;
but, on the removal of the breast, was found to be a distinct growth,
completely separable from the mammary gland, which was pressed aside
by it. Its character was obscured by suppuration in many points of its
substance ; yet, after a careful examination of it in the recent state, and
a repeated examination of the notes and sketches that I made of its
structure, I can only conclude that it was a myeloid tumor suppurated,
or, possibly mingled with cancer.
Eiglitcen months after the removal of her breast, this patient returned
to the hospital, with a large ulcerated tumor in the lower part of her
left axilla, which had begun to form as a distinct tumor six months after
the operation. This was like a large flat ulcerated cancer : it often bled
freely. Her general health was deeply affected by it, and she died in
two or three months after her readmission.
The malignant character manifested in this case was yet more deci-
dedly marked in another. A man, 53 years old, of healthy appearance,
was under Mr. Lawrence's care with an oval tumor, extending, under the
mastoid muscle, from the angle of the jaw to the clavicle. Bloody serum
oozed from it through three small apertures in the integuments. The
anterior part of the tumor felt as if containing fluid ; the posterior part
felt solid, firm, and elastic. He had observed this tumor for ten months,
having found one morning, when he awoke, a lump nearly as large as an
BISTORT OF MTELOID TUMORS. 455
egg, which regnlarly increased. In two months it had become very large :
it was pnnctored, and about one-third of a pint of reddish serum was
discharged from it. In the succeeding eight months it was tapped thirty-
four times more, about the same quantity of similar fluid being each
time evacuated. It was also six times injected with tincture of iodine,
twice traversed with setons, and in various other ways severely treated.
The only general result was, that it increased, and seemed to become,
in proportion, more solid. When admitted under Mr. Lawrence, all the
parts over the tumor were extremely tense and painful, and cerebral
disturbance appeared to be produced by its pressure on the great blood-
vessels of the neck. It was freely cut into, and the surface which was
exposed presented well-marked characters of the myeloid tumors such as
I have described. Some small portions that were removed enabled me
to confirm this with the microscope. The elongated, and the many-
nndeated cells, were, to all appearance, decisive. The incision of the
tumor produced temporary relief; but the tumor continued to grow, and
death occurred nearly twelve months from its commencement. In exami-
nation after death, the solid portion of the tumor formed five-sixths of
its bulk, the rest consisting of a suppurating cavity. The microscopic
eharacters of the solid part were exactly like those of the portions removed
during life, though the substance appeared firmer and whiter than before,
f and yielded, when scraped, a creamy fluid. Four small masses of simi-
lar substance were found in the lungs; and a similar material was difiused
in one cervical gland.
Now, in both these cases, and especially in the last, the whole history
of which seems full of anomalies, there were certainly such features of
dissimilarity from the usual general characters of the myeloid tumors,
that, although the microscopic characters appeared identical, yet they are
not enough to prove even the occasional malignancy of the disease : they
are enough to make us cautious ; enough to induce us to study this dis-
ease very carefully, as one of those that may, in different conditions, or
in different persons, pursue very different courses ; appearing in some as
an innocent, in others as a malignant disease. The use of such terms
as ^^ semi-malignant," ^^ locally malignant," ^4ess malignant than cancer,"
and the like, in relation to growths of this kind, involves subjects of sin-
gular interest in pathology, as well as in practical surgery. But I will
not now dwell on them. The whole subject may be more appropriately
^scussed in the lectures on malignant tumors.
456 OSSEOUS TUMORS.
1=
LECTURE XXVIII. t
I
}
PART II. i
OSSEOUS TUMORS.
Much of the general pathology of osseous tumors has been considered
in the last two lectures, which have treated of the tumors composed of
rudimental bone-textures. Ossification may ensue in either a cartila^-
nous or a myeloid tumor. In the latter it is rarely, if ever, more than
partial, in the former it may be complete ; and the cartilaginous may be
transformed into an osseous tumor. The name of osseous tumor is, how-
ever, not usually applied to those in which ossification is in progress. It
is reserved for such as are formed wholly of bone, and of these alone I
shall now speak.
Osseous tumors, even more generally than cartilaginous, are connected
with the bones, with which, moreover, though they may have the other
characters of tumors, they are almost always continuous, after the manner
of outgrowths. They are, however, occasionally found in soft parts, as
distinct and discontinuous tumors, invested with fibro-cellular capsules.
Thus in the College Museum (No. 203), is a small, completely osseous
tumor, formed of soft cancellous tissue with medulla, which lies over the
dorsal surface of the trapezial and scaphoid bones, completely isolated
from them and all the adjacent bones. In the Museum of St. George's
Hospital is a tumor formed of compact bony tissue, which lay over the
palmar aspect of the first metacarpal bone, loosely imbedded in the fibro-
cellular tissue, and easily separated from the flexor tendons of the finger.*
It had been growing five years in a middle-aged woman. So, but rarely
and imperfectly, the cartilaginous tumors over the parotid gland are
ossified ;t and those in the lungs| and testicle.
At present, these isolated osseous tumors are interesting for little more
than their rarity. It is to those connected with bones that I must now
particularly address myself.
I have already said that these have the character of continuous growths;
*hat they are like outgrowths rather than tumors. And it is not easy to
draw any line of distinction between what deserve to be considered as
tumors, and such accumulations of bone as may ensue in consequence of
superficial inflammation, or other disease, of the bone or periosteum.
The exostoses and hyperostoses of nosology are not to be severally defined
without artifice ; but, in general, we may take this as a convenient, and per-
• An account of it is reported in the Medical Times, Aug. 3, 1850.
t Mu8. Coil. Surg. No. 204.
j; Museum of St. Thomases Hospital.
OSSEOUS TUMORS. 457
lokfs a justy method of dividing them : namely, that those maj be reckoned
18 osseons tumors, or outgrowths of the nature of tumors, whose base of
attachment to the original bone is defined, and grows, if at all, at a less
rate than their outstanding mass.* Those which are not of the nature of
tumors are generally not only ill-defined, but widely spread at their bases
of attachment; and the additions made to them increase their bases
rather than their heights or their whole masses.
Of osseous tumors, thus roughly defined, two chief kinds may be ob-
served ; namely, the cancellous and the compact or ivory-like, which>
generally speaking, may be said to resemble respectively, the medullary
tissue, and the walls or compact substance, of healthy bone. In both
ilike, the bone is usually true and good bone. By my own observations
of it I know no more than this ; but Mr. Quekett, who has submitted to
microscopic examination portions of all the osseous tumors in the College
Museum, confirms the general statement in all particulars. In different
specimens there may be varieties in the proportion and arrangement of'
bloodvessels, and in the size and development of the bone-corpuscles or
hcansd and their canals ; but the proper characters of the bone of the
species in which the tumor occurs are not far departed from.
I believe the homology of the osseous tumors is, in chemical qualities,
u perfect as it is in structure ; and that as with the natural bones, so
with these, we may not ascribe differences of hardness or density to the
diSisrent proportions of the organic, and of the saline and earthy com-
ponMits ; but to the different manner in which the similar material that
they compose is, in different specimens, compacted. Their varieties of
hardness depend on mechanical rather than on chemical differences.
Of the general methods of ossification of cartilaginous tumors I spoke
in my last lecture, and then noticed that in nearly all cases when the
ossification of the tumors is completed, they consist of a very thin layer
or wall of compact tissue, covering in a mass of cancellous and medullary
substance: and thus they are composed, whether the cartilage-growth
began within or upon the bone. It is probable that, in some instances,
the hardest osseous tumors may be also formed by transformation of
cartilage into bone. Thus, in an exceedingly hard ivory-like tumor at
the angle of the lower jaw, in the Museum of the College,! has so ex-
actly the nodular and irregularly spheroidal shape belonging to carti-
laginous tumors, and to the rare cancellous bony tumors in the same part,
that we can scarcely doubt it had a primordial cartilaginous condition.
So, too, Professor Goodsir tells me, there is in the Museum of the Uni-
versity of Edinburgh a tumor of the humerus, half of which is as hard
and compact as ivory, and half is cartilaginous. In the Museum of
Guy's Hospital there is a somewhat similar specimen : in which, however,
* Mr. Stanley particularly remarks this in relation to operations for removal of exostoses.
(On Disease]} of the Bones, p. 150.)
t No. 1035 : it may be compared with a cancellous tumor of the same form, in the Mu-
seum at St George's Hospital, removed by Mr. Tatuni.
458 OSSEOUS TUMOKS.
the hardness of the bone may be due to inflammatory induration of in
ordinary cancellous osseous growth.
These, however, are probably exceptions to the general rule conomu
ing the compact or ivory exostoses ; for, for the majority of these, Bold-
tansky says tnily that no preparatory cartilage is formed. As, in the
natural ossification of the skull, the bone is formed, not in a matrix oC
cartilage but in fibrous tissue, layers of which are successiyely ossified, lo
probably are the hard bony tumors of the skull formed*
The general characters of the cancellous bony tumors are so neailj
described in the account of the cartilaginous tumors from which they
commonly originate, that I need only briefly refer to them. Thej
usually afiect a round shape, with projecting lobes or nodules, whidi
answer to those of the conglomerate cartilaginous tumors, and are often
pointed or angular. They may, however, be very smooth on their sm^
.face, whether they have grown within bones, whose extended walls fona
now their outer layer, or without them under the periosteum* When
completely ossified, their respective tissues, compact and medullary, are
usually continuous with those of the bone on which they are planted ; and
the later periods of growth seem attended with such mutual adaptation
as may tend towards making one continuous, though deformed, mass of
the old and the new bone.
The singularities of position in which the osseous tumors may be
found, and the important hindrances that may result from their ulte^
ference with adjacent parts, I need not detail ; they are amply enume-
rated by Mr. Stanley.
Of their rates of growth little is known ; but I believe that when a
cartilaginous tumor is completely ossified, the growth of the bony tumor
is extremely slow. However, osseous tumors may be found of an enor-
mous size. The largest that I know is in the Museum of the College.*
It nearly surrounds the upper two-thirds of a tibia, in an irregularly
oval mass, with a nodulated surface, almost entirely covered in by a thin
layer of compact tissue, and cancellous in all its interior. It measures
exactly a yard in circumference, and the limb, which was amputated by
Mr. Gay, a former surgeon of St. Bartholomew's Hospital, weighed
forty-two pounds.
Another tumor of large size is in the Museum of the same Hospital-f
A great nodulated mass of bone is attached to the ischium and pubes,
and formed part of a tumor of which the rest was nodulated cartilage.
The compact, hard, or ivory-like bony tumors occur, especially about
the bones of the head, and present several diversities of form. Some
* No. 3220. It is engraved in Cheselden's Osteographea, Tab. 53, £ 1, 2, 3. A painting
of it is in the St. Bartholomew's Museum,
t Series 1 A. No. 133 } and Series 1, No. 118.
IVORY-LIKB OSSEOUS TUMORS. 459
tie unifonn and simple ; others variously lobed or nodular. The simple
tumors are commonly attached to the skull by narrowed bases, over
which their chief masses are prominent on one side, or all roimd. A
good specimen of this kind is in the Museum of St. Bartholomew's
Hospital,''' which shows, besides, that these tumors may consist of an
exterior hard, and interior cancellous, tissue, respectively resembling and
continuous with the outer table and the diploe of the skull. Some of
these hard tumors have the shape of biconvex lenses, resting with one
convex surface on the skull ; and of such as these more than one may
be found on the same skull-f
A disease much more formidable than these exists in the nodulated
and larger hard osseous tumors connected with the bones of the skull.
These are not like outgrowths from the outer table and diploe ; for they
often, or I believe usually, grow first between the tables of the skull, or
in the cavities of the frontal or other sinuses. Increasing in these
parts, they may tend in every direction, penetrating the tables of the
dndl, and forming large masses, projecting as much into the interior of
the skull as on its exterior.
The most frequent seat of such tumors is in the frontal bone, espe-
cially about its superciliary and orbital parts ; and they are horrible by
their pressure into the cavities of both the cranium and the orbit, com-
preasing the brain, and protruding one or both eyes.
The characters of the disease, so far as the growth is concerned, are
well shown in a huge mass which grew from the forehead of an ox,
oiiginating apparently in the frontal sinuses.^ It is like a great sphe-
roidal mass of ivory, measuring 8| inches in diameter, and weighing
upwards of sixteen pounds. Its outer surface, though knobbed and
ridged^ is yet compact, like an elephant's tusk ; and, in similar likeness,
its section shows at one part a thin investing layer, like the bone covering
the ivory. It is nearly all solid, hard, close-textured, and heavy ; only
a few irregular cavities, and one with smooth walls, appear in its interior,
and you may trace the orifices of many canals for bloodvessels. Mr.
Quekett found that this tumor had a higher specific gravity than any
bone, except that which is found in what are called the porcellaneous
deposits, or transformations, in the heads of bones affected with chronic
rheumatism. But it has in every part the structure of true bone.
Just like this, in the general characters of their tissue, are the hard
bony tumors from the human frontal bone. In one, an Hunterian
8pecimen,§ such a tumor, 2^ inches in diameter, deeply lobed and
knotted, fills the frontal sinuses and the upper part of the left orbit,
* Series 1, 71. Series 1 a, 124, in the same Museum, and No. 3215 in the Museum of
the College^ are nearly similar specimens.
t Mus. CoU. Surg. 793. See also Miller's Principles of Surgery, p. 476.
X Mus. ColL Surg. 3216.
§ Mils. Coll. Surg. 795. It is engraved in BailUe*s Morbid Anatomy, Fasc. x. pi. 1, fig. 2 ;
and in Home, Philosoph. Trans., vol. Ixxxix. p. 239.
460 OSSBOUS 0TEKQB0VTH8.
encroaches into the right orbit, and projects for nearly an inch on botk
the surfaces of the skull. It appears to hare originated in the ethmoidil
or frontal cells, and, in its growth, to bare displaced and destroyed
b; pressure the adjacent parts of the tables of the skull and the will of
the orbit. It is, for the most part, as hard as ivory, but in its central
and posterior portion is composed of very close cancellous tossue.
A specimeDj far surpassing this in size, but resembling it io all it>
general characters and relations, is in the Museum of the ITniTerwty of
Cambridge, and is represented in fig. 77. It is the largest and beat
specimen of the kind that I have seen, and its osseous structure is £^
tinct ; only, as Professor Clark has informed me, it is irregular : in the
hardeet parts there are
neither Haversian e»
nals nor lacmtse ; in tbe
less hard parts, the ca>
nals are very large, and
the laconse are not ar-
ranged in circles aroimd
them; and everywhere
the laconse are of ii^
regular or distorted
forme.
A smaller specimen ia
in the Museum of St
Bartholomew's Hospi-
tal. A girl, twenty yean
old, was admitted witb
protrusion of the left eyeball, which appeared due to an osseous growth
projecting at tiic anterior, upper, and inner part of the orbit. None bnt
the anterior boundaries of this growth could be discerned. It had been
observed protmdbg the eye for three years, and had regularly increased ;
it was still increasing, and produced severe pain in the eyeball, and aboct
the side of the head and face. It seemed, therefore, necessary to attempt
the removal of the tumor, or at least to remove some part of it, with the
hope that the disturbance of its growth might lead to its necrosis and
separation. A portion of it was with great difficulty sawn off; but the
patient died with suppuration in the membranes of the anterior part of
the cerebrum.
Now all these cases, corroborated as they arc by others upon record,
prove the general character and relations of these tumors. Their nodu-
lar form, and uniform hard, ivory-like texture ; their growth in the diploe
or sinuses, as isolated or narrowly attached masses ; their tendency to
extend in all directions ; their raising and penetrating the bones of the
skull, and growing into the cavities of the skull and orbit ; all show the
* Fig, 77. Hard bony lumor of the skull : rrom llie Cambridge nniTenilf i
OSSEOUS TUMOKS IN THE TOES. 461
exoeediDg dijQSculty and peril of operations on them. The simpler kinds,
that only grow outwards, may indeed be cut off with advantage, though
seldom without great difficulty ; and, often, the attempt to remove them
has been made in vain ; but these larger and nodular tumors about the
brow can very rarely be either cut off or extirpated.*
The extirpation, however, which may be impossible for art, is some-
times effected by disease; these tumors are occasionally removed by
doughing. Such an event happened in a case related by Mr. Hilton ;t
and the great ivory-like mass, clean sloughed away, is in the Museum at
6uy*s. So, too, in a case by Mr. Lucas, a bony tumor at the edge of
the orbit, after growing eight months, was exposed by an incision through
the upper eyelid. The wound did not heal ; the tumor continued to
grow; and, twelve months afterwards, it became ^' carious," and was de-
tached. The course of treatment which these cases suggest has been, I
believe, the only one worth imitation ; namely, exposure of the tumor,
ind application, if need be, of escharotics to the surface of the bone.
These hard, osseous tumors are very rarely found in connexion with
any bone but those of the skull. In the College Museum, however, is a
wdl-marked specimen in the lower jaw; a nodulated mass, nearly three
inches in diameter, invests the right angle of the jaw, and is, in its whole
substance, as hard and heavy as ivory. I have already, also, referred to
cases of similar hard tumors on the humerus : but they arc extremely
rare.
Osseous tumors of the lower jaw appear to be less rare in animals in-
ferior to man ; for the College Museum contains three specimens,! taken
respectively from a Virginian opossum, a cat, and a kangaroo; and,
which is more singular, one from a codfish. In this specimen, § a disk-
shaped mass of bone, two inches in diameter, extremely heavy and
compact, is attached to the inner surface of the superior maxillary bone.
In the texture of these very hard, bony tumors connected with the
bones of the skull and the lower jaw, we may observe an instance of the
general rule or likeness between tumors and the parts most near to them ;
for their bone is like no other natural bone so much as the internal table
of the skull, or the petrous bone, or inferior maxilla.
The same likeness is observable in the osseous tumors that are frequent
on the last phalanx of the great toe, which, alone, now remain for me to
speak of.||
No adequate explanation, I believe, can be offered for the occurrence
of these growths. They may bo sometimes referred to injury ; yet the
effects of injury to the great toe are so inconstant, that we cannot refer
* The histories of some specimens in the Museum of St. George's Hospital illustrate
these statements very well See, also, Mr. Hawkins's Lectures (Med. Gaz. vol. xxi.)
t Guy's Hospital Reports, vol. i.
X Noe. 1036-7-8.
$ No. 1039. A similar specimen is in tlie Museum of the Boston (U. S.) Me<lical Society.
I Mas. Coll. Sur}^, 787-8-9, 790.
460
08BEOU8 OTBEft'
encroacbes into the right orbit, and pro'
the surfaces of the skull. It appears tr
or frontal cells, and, in its growth, '
by pressure the adjacent parts of the '
the orbit. It is, for the most part, »'
and posterior portion b composed of '
A Bpecimeu, far surpassing this in
general characters and relations, is ii
Cambridge, niid is Teprrsentcd in f,
Bpecimcn of the kind tbat 1 Imvp «»
tinct ; only, as Professor Clark hi
protrusion nf the left oycball, ivhicha
projecting at the anterior, upper
the anterior boundaries of this growtll
observed protmdtng the eye for three y^
It was still increasing, and produced sevx*
the side of the hi':nl sind fiico. It seemed
the removal of the luiimr, or iit Irast to «
hope thjit the <lisliirb;iiiee of it,* ;;rowth
separiitioii. A portion of it «iis with gr
patient dieil with (^upjiuruiinn in ilie nier
the eeri'brinn.
Now alt tlu'se east's, cori-nl'iriit.-d :is th
pntve the general iliarintcr mid icbiiiiniB
lar form, and uniform h:iril. ivorv-liki- tcx
or sinuses, as isolated or nnrrowly iittiic
extend in all directions ; thi-ir raiMii<: nn<1
skull, and growing into the <^ivii)rs of tin
■ Fii. 77. Uanl Iwny luiiun of llic i>k<i)l : fioiii i
462 088E0TJS OVEBaROWTHS.
to injury, as other than an indirect cause of the growth of tumors, so
singularly constant as these are in all their characters, and bo nearly ifith-
out exception limited to the one toe of all that are exposed to injnry.
They grow almost always on the margin, and usually on the inner margin,
of the end of the last phalanx of the great toe ; in only one specimen
have I seen such a tumor springing from the middle of the dorsal sur&oe
of the phalanx ; and, in only two similar tumors from the last phalanx
of the little toe. Growing up from the margin, they project under tlie
edge of the nail, lifting it up, and thinning the skhi that covers thctt,
till they present an excoriated surface at the side of the naiL Tfadr
growth is usually very slow, and when they have reached a diameter of
from one-third to one-half of an inch they commonly cease to grow, and
become completely osseous. They are among the tumors whose indepo^
dence is shown not only by abnormal growing, but by the staying of their
growth when they have attained a certain natural stature.
I believe that they are not uniform in their method of development
In some specimens I have seen no cartilaginous basis; the bone appeared
to form in fibrous tissue, as it were following, and at length overtaking,
the fibrous growth. In another, the outer part of the tumor was formed
of a thin layer of fibrous tissue, and between this and the growing bone
was a layer of cartilage, which had externally the stellate nuclei, and in-
ternally the nuclei of ordinary form, among which the processes of IxHie
were extending.
Whichever way the bono is formed, it is, like that of the phalanx itself,
cancellous but very hard, and with small spaces, and comparatively thick
cancelli or laminae bounding them. The outer layer, too, is rough and
ill-defined, so that the growth looks like a branch from the phalanx, and,
like a branch, is apt to sprout again when cut away, unless at least the
end of the bone on which it grows be removed with it.
The account of osseous tumors would be very incomplete, if there were
not added to it some notice of those growths which are most like them,
though they may lie beyond the range of any reasonable or convenient
definition of tumors. Among these are certain growths of the bones of
the face, tumor-like in their most prominent parts, and yet unlike tumon
in that their bases of connexion with the bones are very iU-defined, and
that from their bases the morbid changes in which themselves originated
extend outwards, on the same or even to other bones, gradually subsiding.
In no instances can it be plainer than it is in these, that a nosological
boundary of " Tumors" must be an arbitrary one.
Such growths as these are not very rare in the superior maxillary bone.
Its ascending process may become enlarged and prominent, with an ill-
defined hard swelling, very slowly increasing, and sometimes stopping
short of any considerable deformity. But a much more formidable dis-
ease exists when a large portion of the bone, or the whole antrum, is in-
OSSEOUS OKOWTHS IK THE UPPEK JAW. 468
Tolved ; espeoiallyi because this is apt to be associated with diseases in the
adjacent bones.
An extreme case is shown in a specimen in the College from the
Museiim of Mr. Langstaff.* Two large masses of bone, of almost exactly
symmetrical form and arrangement, project from the upper jaws and
orbits, and have partially coalesced in the median line. They are
xomided, deeply-lobed, and nodular ; nearly as hard and heavy as ivory :
perforated with numerous apertures, apparently for bloodvessels. They
project more than three inches in front of the face, and an inch on each
ode beyond the molar bones ; they fill both orbits, the nasal cavities,
tnd probably the antra, and they extend backwards to the pterygoid
plates. Part of the septum of the nose, and the alveolar border of the
jaw, are almost the only remaining indications of a face. The disease
ajqwars to have 'begun in the superior maxillary bones, and thence to
have spread over the bones of the face ; similar disease, in a less degree,
existing in the bones adjacent to the chief outgrowths.
The patient, who was sixty years old, believed the disease had been
eighteen years in progress, and ascribed it to repeated blows on the face.
He suffered much pain in the face, eyes, and head. His eyes projected
from the orbits : the right, after suppuration and sloughing of the cornea,
shrivelled ; the left was accidentally burst by a blow. During the last
two years of his life he occasionally showed symptoms of insanity, and at
last he died with apoplexy of the cerebral membranes.
The disease very rarely attains so horrible a state as is here shown.
More commonly it is almost limited to the antrum. In this case it may
exist with little deformity. In the Museum of St. Bartholomew's Hos-
pital (i. 62), is a specimen in which both the antra appear nearly filled
by the thickening and ingrowing of their walls; only small cavities
remain at their centres. The new bone is hard, heavy, and nearly solid ;
yet it is porous or finely cancellous, and is neither so compact nor so
smooth on its cut surface as that of the ^^vory exostosis." The same
disease is manifest in a less degree upon the outer surfaces of the maxil-
lary bones, and on the septum and side-walls of the nose.
The disease has a manifest tendency to concentrate itself in the maxil-
lary bones ; so much so, that if a case be met with where only one of
these bones is diseased, it may be removed with a fair prospect that the
disease will not make progress in the adjacent parts. I believe, indecif,
that this has been done, with a satisfactory result, in a case where already
slight increase of some of the bones near the maxillary was observable :
and there was good reason to anticipate the same result in a case on which
Mr. Stanley operated. The patient was a girl, 15 years old, in whom
enlargment of the nasal process of the superior maxillary bone had been
observed for eight years, and was still increasing. It had as yet produced
no pain, and no deformity of the cheek, the orbit, or the palate : but it
• Mus. Coll. Surg. 3236, A.
464 OSSEOUS GBOWTHS ON THS SKULL.
was regularly increasing ; and as it could be certainly expected to increase
even more in width of base than in prominence (this being the common
tendency of the disease), it was thought right to remove the superior
maxillary bone while yet the disease was limited to it. The patient died,
ten days after the operation, with erysipelas. The specimen displiyi
exactly the same disease as do those last described.
Now it sometimes happens that growths like these spontaneously periali,
are separated with the ordinary phenomena of necrosis, and thus ait 1
naturally cured. Such an event was observed in a case under the can |
of Mr. Stanley.
A man, 37 years old, was admitted with a slight convex smooth pro-
minence of the nasal process of his right superior maxillary bone, whid
he had observed increasing for two years, but which of late had not in-
creased or given him any inconvenience. Indeed, he came to the hospital
not for this, but for a swelling of the right gum and the mucous mem-
brane of the hard palate, through fistulous openings in which one cooU
feel exposed dead bone. These had existed for a month. The sweUisg
of the nasal process was so characteristic of the disease I am describing
as to suggest, at once, the existence of such a growth ; but the suppunr
tion and necrosis threw obscurity on the case ; and it was only watched
and treated according to such indications as arose, till, after four months,
the whole of the mass of bone with which the antrum had been filled op
was separated and pulled away.
The appearance of the sequestrum, a nearly spherical mass of hard,
heavy, and finely cancellous bone, an inch or more in diameter, leaves no
doubt of the nature of the disease.* The great cavity which remamed,
opening widely into both the mouth and the nose, gradually contracted,
or was filled up, and the man recovered perfectly.
A similar event, I imagine, happened in a man who exhibited himself
at most of the hospitals in London, two years ago, with a great cavity
where all his right upper jaw-bone and his turbinated bones had once
been, and through which one could see the movements of his pharynx
and palate. This he said had been left after the separation of a great
tumor of bone.
The growths of this kind seem to merge gradually into elevations of
cancellous porous bone, which may be found on various parts of the bones
of the skull, but of the exact pathology and relations of which we have,
I believe, no clear knowledge. Specimens of them are in the Museum
of the College, and the Museum of St. Thomas's Hospital is peculiarly
rich in them. In some there are great thickenings of one or both tables
of the skull, raising up bosses of new bone from half an inch to an inch
in depth, on one or both the parietal bones, or on the occipital or frontal.
In some, all the bones of the face are involved in similar changes. In
some, similar elevations are produced by growth of bone between the
* The specimen is in the Museum of St. Bartholomew's HospitaL
MULTIPLE OSSEOUS GBOWTHS. 465
tebles of the skull, whidi themselves remain healthy. But, as yet, I
bdieve, we can only look at these as strange and uninstmctive things.
The last form of bony growths that I shall mention comprises the
instances in which numerous exostoses occur in the same patient, and the
examples of what has been called the bssific diathesis or dyscrasia. In
the large majority of cases, both cartilaginous and osseous tumors occur
singly : a few exceptions might be found among such as I have been de-
scribing, yet the rule is generally true. But in certain instances a large
number of the bones bear outgrowths which, at least in external shape,
are like tumors. These are commonly regarded as of constitutional origin.
Some, indeed, appear to be so in that sense of constitutional disease,
which implies a local manifestation of some morbid condition of the blood;
but others can be so called only in that sense, by which we intend some
ori^uial and inborn error of the formative tendency in certain tissues or
organs.
Of these last we may especially observe that the tendency to osseous
overgrowths is often hereditary, and that its result is a symmetrical
deformity. A boy, six years old, was in St. Bartholomew's Hospital, five
years ago, who had symmetrical tumors on the lower ends of his radii,
on his humeri, his scapulse, his fifth and sixth ribs, his fibulae, and internal
malleolL On each of these bones, on each side, he had one tumor : and
the only deviations from symmetry were that he had an unmatched tumor
on the ulnar side of the first phalanx of his right forefinger, and that
each of the tumors on the right side was rather larger than its fellow on
the left.
I saw this child's father, a healthy laboring man, 40 years old, who
had as many or even more tumors of the same kind as his son ; but only
a few of them were in the same positions. All these tumors had existed
from his earliest childhood ; they were symmetrically placed, and ceased
to grow when he attained his full stature : since that time they had under-
gone no apparent change. None of this man's direct ancestors, nor any
other of his children, had similar growths ; but four cousins, one femalo
and three male, children of his mother's sisters, had as many of them as
himself.
The swelling on the little boy's forefinger was an inconvenience to him,
and at his parents' request Mr. Lloyd removed the finger. The swelling
consisted of an outgrowth or projection of healthy-looking cancellous
bone, full of medulla, and coated with a thin layer of compact tissue ; its
substances being regularly continuous with those of the phalanx itself.
Many similar cases of symmetrical and hereditary osseous outgrowths
might, I believe, be adduced;* and all their history suggests that they
are to be regarded as related not less closely to malformations, or
monstrosities by excessive development, than to the osseous tumors or
• See Mr. Stanley's Treatise on Diseases of Bones, p. 152 ; and Mr. Hawkins's Lec-
tnres on Tumors of Bones (Medical Gazette, vol. xxv. p. 474).
80
466 DISTINOTIONS OF OSSEOUS GROWTHS, BTO.
outgrowths of which I have been speaking. Indeed, at this point tlie
pathology of tumors concurs with that of congenital excesses of develop-
ment and growth.
We must distinguish from these cases the instances of multiple ossifica-
tions of tendons, muscles, and other tissues, that are occasionally met
with ; for these only imperfectly imitate the forms of tumors, and are
probably connected with such a morbid condition of the blood as really
may deserve the name of ossific dyscrasia or diathesis.
Before ending, it may be proper to point out the chief distinctions
between the osseous tumors, and those growths which are connected with
other tumors springing from the bones ; for, under the vague name of
osteo-sarcoma, many include together, and seem to identify, all growths
in which bone is mingled with a softer tissue.
The growths that may chiefly need distinction are those of osteoid
cancers, and the bony skeletons of certain medullary tumors of bone.
Osteoid cancers are probably examples of firm, or hard, or fibrous cancers,
ossified : and the best marked among them present an abundant forma-
tion of peculiarly hard bone. The distinctions usually to be observed
between these hard osteoid cancers and the hard osseous tumors are
mainly in these particulars :—r{a) the osteoid mass, in its mid-substance,
may be compared with chalk, the osseous with ivory ; the one is dull
and powdery, the other bright and wholly void of friability; (6) the
osteoid is new bone infiltrated, as it were, in some softer tissue, or in the
tissues of the original bone, which disappear as it increases ; the hard
osseous tumor is a distinct growth, attached in a comparatively small
part of its extent to the bone on which it grows ; {c) the outer surface of
an osteoid growth is porous and rough, and, if laminated, its laminae have
their edges directed outwards ; while the outer surface of a hard osseous
tumor is smooth and compact, and, if laminated, the surfaces of its
laminjB are directed outwards ; (d) lastly, the minute characters of bone
are far less perfect in the osteoid than the osseous growth : bone^orpuscles
existing, indeed, but small, round, irregular, with very small, if any,
canaliculi, and imbedded in a porous, chalky-looking, basis-substance.
And, 2dly, for distinction between the softer osseous skeletons of
medullary cancers, and the cancellous osseous tumors, we may chiefly
observe that, (a) the bone in cancers is more dry and friable than the
cancellous bone of the osseous tumors ; and (6) the bone in cancerous
growths has no medulla, the interspaces between its laminse being filled
with cancerous matter ; while medulla is a constant constituent, I believe,
of all the cancellous osseous tumors.
Such are the chief dificrences generally to be observed between the
bone of innocent and that of malignant tumors ; difierences which it is
well to establish, since the fact is sufficiently confusing, that any normal
tissue should be formed in subordination to the growth of cancers. The
subject will be again advctl^id to m live lecture on Osteoid Cancer.
MAMMART GLANDULAB TUMOBS. 467
LECTURE XXIX.
PART I.
GLANDULAB TUMORS.
Wb may call those tumors ^^ glandular" which, in their structure,
imitate the glands ; whether the secreting glands, or those organs which
we name glands, because, though having no open ducts, they are of
analogous structure.
The most frequent example of these glandular tumors is the kind
which imitates, and occurs in or near, the mammary gland ; the chronic
mammary tumor of Sir A. Cooper ; the pancreatic tumor of Mr. Aber-
nethy;* the fibrous tumor of the breast of M. Cruveilhier.f Other
tumors of the same general kind are more rarely found in the lips, and
in or near the prostate and the thyroid glands. Probably, too, some
other tumors, to which no name, or a wrong one, has been hitherto
assigned, may yet have to be placed in this group : indeed, I think it
nearly certain that there are lymphatic gland-growths, which we usually
regard as enlarged glands, but which are really new growths, of the
nature of tumors, even in the most limited sense of the term. At present,
however, I will have in view only such gland-tumors as may be clearly
recognised ; namely, such as the mammary glandular tumor, the labial,
the prostatic, and the thyroid.
Some of the pathology of these tumors has been already sketched in
the account of the glandular proliferous cysts (p. 323 and 358). To that
account I may again refer, so far as to the point at which it is believed that
an intra-cystic growth has completely filled the cyst in which its growth
began, and has coalesced with the walls, so as to form a solid tumor
(p. 359).
Now it is perhaps probable that all glandular tumors may be formed
after this plan : for, in those occurring in the breast, wc find sometimes
one circumscribed mass, composed, half of a proliferous cyst, and half
of a solid glandular tumor ; J sometimes two such growths lie apart, yet
in the same gland (fig. 49) ; and often, we find such structures as we
doubt whether to call proliferous cysts nearly filled, or mammary tumors
(fig. 51).
However, if all the mammary and other glandular tumors are thus of
intra-cystic origin, it must be admitted that many of them very early
lose the cystic form, and continue to grow as solid masses ; for we find
• The mammary tumor described by Mr. Abernethy was probably a medullary cancerous
disease.
t Anatomie Pathol, lir. xxvi. pi. 1 ; and Bulletin de TAcaddmie de M6decine, t. ix. p. 429.
% Mus. Coll. Surg., 177-8.
468 MAMMABT ^LAKDULAB TUHORd
them solid even when they are very small ; and they are traced growing
from year to year, yet apparently maintaining always the same textore.
I shall speak now of the solid tumors alone ; and, first, of the Mam-
mary Glandular Tumors.
Sir Astley Cooper may be said to have had a good insight into their
nature, when he called them ^^ chronic mammary," and said they were
" as if nature had formed an additional portion of the breast, composed
of similar lobes/** The analogy of their structure was also recognised
by Mr. Lawrence.f But I believe nothing more than this general like-
ness had been observed, till these tumors were examined with the micro-
scope by M. Lebert,;!; who found in them the minute glandular stractore
imitative of the mammary gland, and recognised many of their relations
to the proliferous cysts. Mr. Birkett,§ by independent and contempo-
rary observations, made on the great collection of these tumors in Guy's
Hospital, confirmed and extended the conclusions of M. Lebert, and has
cleared up much of the obscurity that existed previous to his inquiries.
Both these gentlemen apply such terms as " Imperfect Hypertrophy of
the mammary gland** to these tumors: but, highly as I esteem Iheir
observations (and not the less, I hope, because they corrected errors of
my own), II I would rather not adopt their nomenclature, since, if we do
not call these "tumors,** I hardly know to what innocent growths the
term could be applied. Nearly all innocent growths are imperfect hy-
pertrophies, in the same sense as these growths are ; nay, these are, in
many respects, the very types of the diseases to which the name of
tumors is by general consent ascribed, and which can be distinguished,
even in verbal definition, from what are more commonly regarded as
hypertrophies.
The mammary glandular tumors may be found in any part of the
breast ; over, or beneath, or within the gland, or at its border. Their
most rare seat is beneath the gland ; their most common at its upper and
inner part, imbedded in, or just beneath, its surface. They are usually
loosely connected with the gland, except at their deepest part, where
their capsules are generally fastened to it : but the connexion is of so
* On Diseases of the Breast, p. 54.
t On Tumors ; in Med.-Chir. Trans., vol. xvii. p. 29. It seems only just to observe that
this recognition of the obvious resemblance between the structure of these tumors and that
of the mammary gland was almost always sufficient, after the description by Sir A. Cooper,
to enable the surgeons of this country to avoid the confusion between the " chronic mam-
mary" tumors and the cancers of the breast, which M. Lebert describes as still prevalent in
France, notwithstanding his own clear description of the points of diagnosis.
X Physiologic Pathologque, t. iL p. 201.
§ On the Diseases of the Breast, p. 124.
I In the Catalogues of the Museums of the College and of St Bartholomew's Hospital
these tumors are classed with the fibroK^ellular. In most of the specimens that I had exa-
mined the fibro-cellular tissue was very abundant, and I thought too lightly of the glandular
tissue which I found mingled with it
HAMMART GLANDULAR TUMOBB. 469
imall extent that they slide very easily under the finger, and are pecu-
liarly movable in all directions.
The tumor is commonly of oval shape; superficially, or sometimes
deeply, lobed or nodular ; firm, or nearly hard, elastic, and often feeling
like a cyst tensely filled with fluid. The parts around appear quite
healthy. The mammary gland is pushed aside ; but it undergoes no
other change than that of atrophy, even when stretched over a tumor of
the largest size. The skin under distension may grow slightly livid, but
else is unchanged. The veins, if the growth of the tumor be rapid, may
be dilated over it, as over or near a cancer of the breast. The tumor is
usually invested with a complete capsule, isolating it from the surround-
ing mammary gland, and often adhering less to it than to the gland.
This capsule may appear only as a layer of fibro-cellular tissue, like that
round any other innocent tumor ; but it is not unfrequently more per-
fectly organized in layers, and smoother on its inner surface ; conditions
that we may perhaps ascribe to its having been a perfect cyst within
which the glandular growth originated, and which the growth has only
lately filled.
On section, these tumors present a lobed construction, in which it is
sometimes not difficult to discern the remains, or the imitation of the
plan, of the lobed, or foliated and involuted intra-cystic growths. In
some the fibro-cellular partitions among the lobes converge towards the
centre of the mass, as if they were the remains of clustered cyst-walls ;
or, there may remain a cavity in the centre of the tumor, as if clustered
cysts and growths had not quite filled up the space. In some, however,
no such plan is discernible ; the whole mass is disorderly lobed, and its
lobes have the shapes derived from accidental mutual pressure, and are
bounded by loose fibro-cellular partitions.
In structure as in construction, these tumors may present several
variations ; but they may be artificially arranged in three or four chief
groups.
Some are really very like the normal mammary gland in an inactive
state. These have a pure Dpaque-white, and soft, but tough and elastic
tissue ; they are lobed, and minutely lobulated, with undulating white
fibres. Such an one is well shown in a specimen from Sir Astley
Cooper's collection,* in which, moreover, his injection of the bloodves-
sels shows a moderate vascularity, about equal to that of the surrounding
normal gland-substance.
We might take such as this as the examples of the medium form of
thb kind of tumor ; and the other chief or extreme forms are represented
by those which deviate from this in two directions. In one direction we
find much softer tumors ;t these, though closely textured, are soft, brittle,
and easily crushed ; their cut surfaces shine, or look vitreous or half
• Mut. Coll. Surg., No. 2772. In this specimen there is also a peculiar warty growth in
the skin over the tumor. t ^^ch as No. 2774 in the College Museum.
470 HAHVAET aLANDDLAS TTTIfORS.
translnceDt ; they are anifomly grayish- white, or have a alight yellowigh
or pink hue, which deepens on exposure to the air ; or they may look
like masses of firm, but flickering jelly ; and commonly we can press
from them a thin yellowish fluid, like serum or synovia. Such as tho»
have the usual lobed and lobular plan of constructioQ ; and I think the
intersecting partitions commonly extend from a firm, fibrous-looking
central or deep part, towards the circumference of the tumor.
In the other direction from the assumed average or mediom form, we
find firmer tumors. These have a drier and tougher texture ; they are
opaque, milk-white, or yellowish, hke masses of dense fibro-cellular tis-
sue, lobed, and having their lobes easily separable; as in the great
specimen, weighing seven pounds, in the College Museum (Ko. 208).
To such as these varieties we might add many, due not merely to
intermediate forms, but to the degrees in which the intra-cystic mode of
growth is manifested ; or to the development of cysts, which may take
place as well in this new gland-tissue as in the old ; or to the Tarioui
contents of the cysts, whether liquids or organized growths.*
I believe we cannot at present always connect these various aspects of
the tumors with any corresponding varieties in their histories. Neither,
I think, have any investigations proved more of the corresponding
varieties of microscopic structure, than that, as a general rule, the
tougher any tumor is, and the slower its growth has been, the more it has
__ of the fibro-cellulor, mingled with its glandn-
^ '*!s^ '*•"» tissue ; while the more succulent and
~>-^i?^>^ vitreous one ia, and the more rapid its growth,
" the less perfectly is the glandular tissue
developed.
The microscopic structures may be best
7 described from a medium specimen : from
■/ such an one I made these illustrative
'' I "' 1 1 w^s' sketches. The patient was 33 years old;
' ll ^^"^"^ the tumor had been noticed seven months,
and was ascribed to a blow ; it was painful
#at times and increasing ; and it had the
***• ^ a <& <»^ .^^ several characters that I have already dc-
M /^-"Hk. scribed. The patient has remained weU
9 a ^0 ^®fe* ^'"*''' '''^ removal.
^^ In such a tumor one finds in thin sections,
traces of a minute lobular or acinous form ; the miniature, wo might say,
of that which we see with the naked eye. The lobules may be merely
* I believe these include Ilie cliief examples of Moilec'e Cysto-cBrcomHtB. One of thes«
tumois containing simple cysts would constitute liis cyslo-BOrcomn simplex: the cysts being
preliferoua wilh gland growlhs would make his cyeto-snrcDms pliyllodes.
t Fig. 78. Minute eltiictures of a mBtnmnry glandular lumot, <leBcribe<l in the lext: mag-
nified 3S0 times. The miftoscopic einmi nations of several specimens may be found in
Leber! (Phys. Pathol, ii. IBO; and Abhandlungon, p. 300); Birkctt, On the Diseases of ttia
fireast,pl. 2, 3, 4, &c.; andBeiine\,0nC»wiennmwi4C»wi\(niGw«'h«,p, 63.
MAMMART GLANDULAR TUMORS. 471
phced side by side, with little or no intervening tissue ; their form
may; appear to depend on the arrangement of their contents, and
these may seem scarcely bounded by membrane. But, I think, more
commonly, especially in the firmer specimens, the plan of lobules or
acini is mapped-out by partitions of filamentous-looking tissue, fasci-
culi of which, curving and variously combined, appear to arch over,
and to bound, each acinus or lobule. But great varieties appear in
the quantity of this tissue; it may be nearly absent, or it may so
predominate as to obscure the traces of the essential glandular struc-
ture.
This proper gland-structure consists of minute nucleated cells and
nuclei, clustered in the lobular form, or in that of cylinders or tubes,
and often, or perhaps always in their most natural state, invested with
a simple, pellucid, limitary membrane.
Thus, the likeness is striking between the structure of such a tumor
and that of an inactive mammary gland, such as that of a male, as Mr.
Birkett has pointed out. We have here what may be compared with the
round or oval csecal terminations of the gland-tubes clustered together
and often seeming grouped about one trunk-tube ; and in these we have
the simple membrane and the gland-cells and nuclei within ; only, the
main duct is wanting, and the communication with the ducts of the proper
gland. It is as if the proper secreting structure of a gland were formed
without connexion with an excretory tube ; the tumor is, in this respect,
like one of the glands without ducts.
The mammary glandular tumors are singularly variable in all the par-
ticulars of their life. They sometimes grow quickly ; as did the largest
figured by Sir A. Cooper, which, in two years, acquired a weight of a
pound and a half. In other cases their growth is very slow ; I have
known one* which, in four years, had not become so much as an inch in
diameter. In some instances they remain quite stationary, even for many
years. Onef was removed from a woman 27 years old : it was observed
for 14 years, and in all that time it scarcely enlarged ; yet after this it
grew so rapidly, that in six months, it was thought imprudent to delay
the removal. Cases of this arrest or extreme retardation of growth
must have been seen by most surgeons ; but there are few cases so strik-
ing as one related by M. Cruveilhier, in which a lady had, for more than
20 years, three of these tumors in one breast, and one in the other. She
died in consequence of the treatment employed against them, and after
death no similar disease was found in any other part.
Equal variations exist in regard to pain. Commonly these tumors are
painless ; but sometimes they are the seats and sources of intense suffer-
ing ; even of all that sufiering which is popularly ascribed to cancer, but
which cancer in its early stages so very rarely presents. The irritable
tumor of the breast, as Sir A. Cooper named it, was in most of his cases
♦ Museum of St. Bartholomew's, Ser. xxxiv. No. 23. f Mus. Coll. Surg , 207 b.
472 MAMMABT GLANDULAR TUMORS.
a mammary glandular tumor ;'*' and the character of the pain, like that
of the painful subcutaneous tumor (p. 894), is such as we may name
neuralgic.
A tumor,t evidently glandular, was taken from the breast of a womtn
25 years old, where it had been growing for two years; it had often been
the seat of the most intense pain. I referred to a similar case while
speaking of neuralgic tumors (p. 396), and I removed a similar tumor
from the breast of a young lady, who begged for its removal only that
• she might be relieved from severe suffering. In all these cases the
minute glandular structure was well marked.
A peculiarity of these tumors is, that they not unfrequently disappear;
an event very rarely paralleled in any other tumor. They are most likelj
to do this in cases in which any imperfection of the uterine or ovarian
functions, in which they may have seemed to have their origin, is re-
paired by marriage, or pregnancy, or lactation. And the fact is verj
suggestive: since, in many cases, it appears as if the discontinnou
hypertrophy, which constitutes the tumor, were remedied by the supe^
vention of a continuous hypertrophy for the discharge of increased fune-
tions of the gland.
On the other side, these tumors often continue to grow indefinitely and
they may thus attain an enormous size. One was removed by Mr.
Stanley, which, after twelve years' progress, in a middle-aged woman,
measured nearly twelve inches in length, and weighed seven pounds. It
was pendulous ; and, as she sat, she used to rest it on her knee, till the
integuments began to slough. Mr. Stanley merely sliced it off, cutting
through the pedicle of skin ; and the patient remained well for at least
seven years. The tumor was one of the firmest and most filamentous of
the kind. J
In the College Museum is a tumor§ of the same kind, but softer and
much more succulent, which was removed by Mr. Liston from a woman
44 years old, and which weighed twelve pounds.
Respecting the origin of these tumors, little more, I believe, can be
said than that, occurring most commonly in young unmarried or barren
women, their beginning often seems connected with defective or dis-
ordered menstruation. The law which, if we may so speak, binds to-
gether in sympathy of nutrition the ovaries and the mammary glands,
the law according to wliich they concur in their development and action,
is not broken by one with impunity to the other. The imperfect oflBce
of the ovary is apt to be associated with erroneous nutrition in the mam-
mary gland.
I have seen only one specimen of the mammary glandular tumor in a
male. A portion of it was sent to me by Mr. Sympson, and its characters
• Under the same name, however, he inohided some that were more probably " Painful
subcutaneous Tubercles:" see his pi. viii. figs. 2, 4, 5, 7.
t Mus. St. Bartholomew's Hospital, Ser. xxxiv. No. 22.
J Mus. Coll. Surg., No. 208. § Mus. Coll. Surg., Na 2 10,
MAMMABT GLANDULAR TUMORS. 478
were well marked. It was removed by Mr. Hadwcn, from a country-
man, 25 years old, in whom it had been growing irregularly, and oc-
casionally diminishing or disappearing, for about five years. When re-
moved, it formed a circular, flattened, and slightly lobulated tumor, 3}
inches in diameter, and an inch in thickness, invested with a distinct
fibro-eeUular capsule, which loosely connected it to the adjacent tissues.
There are, I believe, no facts to suggest that the glandular tumors
are, as a role, other than innocent. More than one may grow in a
breast at the same or several successive times ; but I have not known
of more than three either at once or in succession. Neither am I aware
of any facts which prove what is commonly believed, that, after a time,
these tumors may become cancerous. Such things may happen ; and,
on the whole, one might expect, that if a woman have a tumor of this
kind in her breast, cancer would be more apt to aflfect it as a morbid
piece of gland, than to affect the healthy gland. But, I repeat, I know
no facts to support this ; and some that I have met with are against it.
Thus, in the Museum of St. Bartholomew's, is a portion of breast,* from
a young woman 82 years old, in which there lie, far apart, a small mam-
mary glandular tumor that had existed four years, and a hard cancer
that had existed four months. A second specimenf shows a hard cancer
and a proliferous cyst, in the breast of a patient, who died some time
after its removal with recurrence of the cancer. A third case, just like
the first, was imder Mr. Stanley's care. In these cases, at least, the
tmnor was not selected as the seat for cancer ; and I believe that they
are not counterbalanced by any of an opposite kind.
And yet, while all the characters of innocent tumors are generally,
if not always, observed in these, there are facts concerning a seeming
connexion between mammary glandular tumors and cancer which must
not be passed by here ; though they may need to be again stated in the
last lectures on cancer.
It has sometimes happened that a glandular tumor has been removed
from a breast, and, within a short time, the same breast has become the
seat of cancer.^ I believe that the explanation of such cases as these
may be; that a woman, prone to cancer by some constitutional condition,
or, especially, by hereditary disposition, had (as any other might) a glan-
dular tumor in her breast ; and that the operation for removing this
tumor inflicted a local injury, and made the breast apt to be the seat of
cancer, of which already (as one may say) the germ existed in the blood.
Such events may prove only an accidental connexion between the glan-
dular tumors and the cancer ; but they are enough to suggest great
caution in operating on the breasts of those who may be suspected to be,
by inheritance, peculiarly liable to cancer.
♦ Scr. xzxiv. No. 17. f Mus. St. Eartliolomew^s Hospital, Scr. xxxiv. No. IC.
J See such a case, by Mr. Erichsen, in the Lnncet, Feb. 14, 1S52 ; and the history of a
leries of prepanitions in the Catalogue of the Museum of St. Bartholomew's, vol. i. p. 44G.
474 MAMMABT GLANDULAB TUMOBB.
Bat, again, cases sometimes occur in which, I think, the mammary
glandular tumors supply examples of what I have already suggested u,
probably, a general truth : namely, that the children of a canceroin
parent, or those in whose family cancer is prone to occur, are apt to
have tumors which may be like innocent tumors in their stmcture, but
may resemble cancers in a peculiar rapidity of growth and a proneness
to ulceration and recurrence after removal. A striking instance of thk
occurred in Mr. Lawrence's practice. He removed the breast of a ladj
from one of whoso sisters Mr. Aston Key had removed a breast said to
be aifected with '^fungoid'* disease, whose mother had died with well-
marked hard cancer of the breast, and in other members of whose family
cases of cancer were believed to have occurred. The breast removed by
Mr. Lawrence comprised a huge sloughing and ulcerating mass of yd-
lowish, soft, flickering substance, like the softest of these mammaiy
glandular tumors, or like the very soft pellucid growths which I hate
described as occurring in some of the proliferous cysts of the breast
The diseased state of the mass (in consequence of escharotics having,
been recklessly used) was such, that minute examination showed little
more than the absence of distinct cancer-structures. During the healiog
of the wound, and for some months after it, fresh growths repeatedly
appeared. Some of these which I examined were yellow, pellucid, soft,
viscid, almost like lumps of mucus, or of half-melted gelatine, imbedded in
the tissues of the integuments or scar. With the microscope I found
only granules and granule-masses with elongated nuclei, themselves aho
granular, set in abundant pellucid substance. I found no sign of cancer-
structure or gland-structure. The substance resembled that which I
have mentioned (p. 362) as found in some imperfect proliferous mam-
mary cysts.
Now, after repeated removals of such growths as these, the wounds
completely healed, and the patient has remained well, and in good general
health, for eighteen months.
At nearly the same time, a third sister of this family was under Mr.
Lawrence* 8 care ; and he removed one of her breasts in which was a
great mass, which had grown quickly, and was chiefly composed of well-
marked glandular tissue, either in separate solid growths, or inclosed m
proliferous cysts. But some parts also of this tumor were soft, pellucid,
and gelatinous ; and others were as soft, but opaque and dimly yellow.
In the firmer parts, the glandular textiure was as distinct with the micro-
scope as with the naked eye : in the softer parts no such structures were
seen, but abundant free cells and nuclei, of most various and apparently
disorderly shapes ; some elongated, like small shrivelled fibro-cells ; some
flattened, like small epithelial cells. I would not venture on an opinion
of what these were or indicated : I think they were not cancerous, and
the disease has not returned. The main fact of all the cases is, that
three daughters of a cancerous mother had mammary tumors ; in two, at
LABIAL GLANDULAR TUHORS.
475
least, of them the stmctiire was probably not cancerous ; and ;ct the
npid growth, the recurrrace in one of them, and the defective or disor-
dered modes of growth in both, were such as marked a wide deviation
from the common rules of mammary glandular or any other innocent
tnmors, and a deviation in the direction towards cancer.
Labial glandular tumors may be briefly described, for their general
dttracters correspond closely with those of the foregoing kind; or, thoy
may appear intermediate in character between the foregoing and those
tnmore which I described as lying over or near the parotid gland, and as
oonsisting of mixed glandular and cartilaginous tissue. Their iikenese to
these tnmors over the parotid was manifest to Mr. Lawrence, who has
added to his account of the tumors by the parotid, the only case of labial
glandular tumor that I have found on record.*
The most marked case of labial glandular tumor that I have seen was
that of a healthy-looking man lately under the care of Mr. Lloyd.
A tnmor had been growing in his upper hp for twelve years. It was not
punfol, but the protrusion of the
lip was inconvenient and ugly, the fis.j9.»
nellmg being an inch in diameter.
It was imbedded in the very substance
of the lip, both the skin and mucous
membrane being tensely stretched over
it Its form was neariy hemispherical,
its posterior surface being flattened as
it lay close on the gums and teeth,
its anterior convex and smooth. Its
whole substance was firm, tense, and
elastic.
Mr. Lloyd removed the tumor with
the mucous membrane over it, leaving
the skin entire. The tumor was firm,
slightly lobed, yellowish-white, smooth.
In general aspect, it resembled the
mixed tumors over the parotid, hut in '
miDate structure it presented as perfect
an imitation of lobulated or acinous
gland-etmctnrc as any mammary glan-
dular tumor. Its tubes and their di-
lated ends had distinct limitary mem- q
brane, and were filled with nuclei and
nucleated cells, like those of the labial glands (:
• MeJico-Chinirgical TranraeiionB, tdL
t Fig. 70. A, Mruciure like the
e portion of giBnil-like
0 ^ %Q)
6g. 79). I heard some
p. 88.
.- alions of gtami-diicU
giBiiii-ute luae; c, Hparale BlnnH-cellf, nnd free
rdsKiibediD the lexc. a anil a, n»|[uiticd 300 lime«
luclei \ from tlie labial
476 THYBOID OLAKDULAB TVMOBB.
months afterwai*ds that another tumor was growing in the same lip ; Intt
the patient was lost sight of. Such a recurrence, even if it really hap-
pened, would be no sufficient evidence of malignancy.
I removed a similar tumor from the upper lip of a man about 80 yean
old. It had been regularly growing for four years without pain, and
projected far externally, reaching to the same distance as the end of Ui
nose. This had a texture of glandular kind, but less distinctly marked
than that in the former case. Moreover, in the centre of the mass ma
a portioa of bone ; a peculiarity which existed also in Mr. Lawrence's j
case, and which may add to the probability of relationship between '
these tumors and the mixed glandular and cartilaginous tumors over the
parotid.
Lastly, I may again refer to a specimen in the Museum of St. G^rge'i
Hospital, in which, in one tumor, a cyst and what looks like one of ihm
glandular growths are combined (see p. 862).
Prostatic glandular tumors were briefly referred to in the finft
lecture (p. 323), as examples of the abnormal growths by which tmnois
appear to be connected with simple hypertrophies of organs ; and I caa
add little to what was then said of them.
We owe to Bokitansky* the knowledge that the tumors in the prostata
gland, which were commonly, and till lately even by himself, regarded
as fibrous tumors, are composed of tissues like those of the prostate gland
itself. In enlarged prostates they are not unfrequently found. In coV
ting through the gland, one may see, amidst its generally lobed atmctaie,
portions which are invested and isolated by fibro-cellular tissue, and may
be enucleated. Such portions have, I believe, been sometimes removed
as tumors, or as portions of prostate gland, in operations of lithotomy.
They lie embedded in the enlarged prostate, as, sometimes, mammary
glandular tumors lie isolated in a generally enlarged breast. They look
like the less fasciculate of the fibrous tumors of the uterus : but, to micro-
scopic examination, they present such an imitation of the proper strac*
ture of the prostate itself, that we cannot distinguish the gland-cell or
the smooth muscular fibres of the tumor from those of the adjacent por-
tions of the gland. Only their several modes of arrangement may be
distinctive.
At present the examinations of these tumors have been too few to fur-
nish a complete history of them : neither can I add any cases or refe-
rences to those which were adduced in the first lecture.
The THYROID GLANDULAR TUMORS Were similarly referred in the same
lecture. Their history is merged in that of bronchoceles, with which
they are usually associated, whether imbedded as distinct masses in the
enlarged gland, or lying close by it, but discontinuous. Yet I suspect
* Ueber die Cyste, 1849; and, Anatomie des Kropfei
BEBCTILB OB VASCULAR TUMORS. 477
that similar growths, of substance like thyroid gland, may occar, as
tnmors, further from the normal mass of the gland.
Mr. Stanley removed a tumor from the neck of a woman 62 years old.
It had been observed for 50 years ; for the first 80 of which it was like a
little loose "kernel" under the skin, and scarcely increased. In the next
ten years it grew more quickly, and in the next ten more quickly still ;
ftnd now, the skin over it ulcerated, and it protruded and occasionally
Ued, but was never painful. It looked like an ulcerated sebaceous
cyst, seated upon the subcutaneous tissue at the lower part of the neck,
JQSt in front of the trapezius. No cause could be assigned for it.
On section it appeared as a solid tumor with a thin fibro-cellular cap-
sule, partitions entering from which divided it into distinct round lobes.
Its proper substance was soft, elastic, glistening, yellowish, blotched
and streaked with brownish pink and blood colors. It was, to the naked
eye, like a piece of bronchocele, with such an arrangement of its parts
as would exist when numerous cysts are filled with the glandular growth,
and compacted. And the general impression hence derived was confirmed
by microscopic examination, which showed that the tumor consisted,
chiefly^ of round and oval bodies, or minute sacculi, from j^q to ^io of
an inch in diameter, filled or lined with nucleated substance, or with nu-
dei imbedded in a dimly molecular blastema, and not nucleolated. These
bodies were closely apposed, but frequently appeared separated by thin
filaments, or fibro-cellular partitions. The nuclei were very uniform,
drcnlar, about ^jfifji of an inch in diameter, and in general aspect like
the nuclei of vascular glands or lymph-glands. Numerous similar nuclei
appeared free ; and some appeared imbedded in a dimly molecular blas-
tema, which was not enclosed in cysts or sacculi, nor divided by fibro-
oellulor partitions.
I have seen no other tumor like this ; nor any natural texture that it
resembled, except the thyroid gland. Future observations must prove
whether thyroid glandular tumors can be formed so far from the normal
gland, with the cervical fascia, great bloodvessels of the neck, and other
adjacent parts intervening between them.
LECTURE XXIX.
PART II.
BRECTILE OR VASCULAR TUMORS.
Thb erectile or vascular TUMORS include most of the diseases
which are described as vascular naevi, and of which the types are the
subcutaneous nssvL Among them, also, are the growths to which John
478
BKEOTILB OB TA8CDLAR TDMOBB.
Bell gave the niunc of aneuriBin by anaBtomosis, and those which hin j
been called Telangeiectasis. !
The name "erectile tumor" has, of late years, come into general m,
as expressing a principal fact concerning these diseases, namely, tbt
many of them resemble very closely in their texture that of erect3e«
cavernous tissue. Mr. Humphry* has, indeed, rightly objected to the w
of the term, that these tumors present no imitation of the erectile tioH
in the power of filling themselves with blood, aa if by some inteml
force. But, since this occurrence in the true erectile tissue depends ■■
much on the accessory structures of nerves and muscles as on the tina
itself, we may fairly apply the term "erectile" to the tomorB; remain
boring only this, as for other structures occurring in tumors, tiiat Ai
imitation of the natural tissue is imperfect, or partial. However, if my
be scrupulous in tho use of these terms, they may call these tumon t»
cular, or cavernous, or even Telangeiectasis.
The likeness which these tumors bear to the erectile tissue, as ezea-
plificd in the corpus cavemosnm penis, is sometimes, in general appeu^
ance, perfect. A well-marked epea-
men is in the Hunterian coUeetial^t
from which the adjoining sketch ww
made (fig. 80). It was remored fro*
under the lower jaw, and its cat ^^
face displays a close network or sponie
of fine, smooth, shining bands and
coi;ds, just like those of the corpus «•
vernosum penis, only less regular m
their arrangement. The opportumtic*
of examining such tumors in the recent
state are very rare ; and they are 0B»-
ally spoiled by the operations for re-
moving them ; but what I have seen,
and the descriptions which others have
recorded, leave little doubt that tbit
imitationof erectile tissue isairequnt
character among them.
John Bell's account§ of the aneurism by anastomosis, which is by far
the most vivid and exact, in relation to the history of the disease, thst
has yet been published, accords with this statement. Although he had
chiefly in view the arterial variety of these tumors, yet of one he says, —
"The substance of it was cellular, stringy, and exactly resembling the
corpora cavernosa penis . . . the cells were filled with blood from the
arteries, which entered the tumor in all directions." Another he com-
* Leclures on Surgery, ji. 111.
t Fig. 80. Seclion of Rii erectile tumor in tlie College Museum, deacribed above. It u
Jrau'n onp-ihiiil larger, anil rathec coarser, than naturaL
J Mus. Coll. StJig. 301 K. ? rriooiplo* of Snrgeiy, toI. i. p. 456, c. *.
BRBCTILB OB VASCULAB TUMOBS. 479
pares to a sponge soaked in blood ; and the descriptions of other exam-
ples, though less explicit, imply the same. The descriptions by Mr. War-
drop* and Mr. Caesar Hawkins,t and the more minute accounts of struc-
ture by Mr. Gt)odsir,;|; and Mr. Liston,§ and Rokitansky,|| confirm this
▼icw; and neither Mr. Birkett's,^ nor any other that I have met with,
« discordant from it.
The essential structures of the disease are, according to these descrip-
tions, derived from such a growth of bloodvessels, or rather of blood-
qiecies, that, in imitation of erectile tissue, the whole mass seems formed
cf cells or spaces, opening widely into one another : and, in extreme
cases, no remains exist of the walls of the vessels, except those narrow
bands and cords that bound and intersect the cell-like spaces.'*''*'
The division, often made, of erectile or vascular tumors into such as
are named, respectively, " arterial," " capillary," and '' venous," is con-
venient, and probably well-founded. The most frequent examples of
subcutaneous nsevi, and the more frequent superficial naevi, which are
like them in structure, though diiferent in position, appear to consist,
mainly, of closely arranged minute bloodvessels, of which some arc as
small and as simple as medium-sized capillaries, while others, of various
siie, appear as dilated capillaries, or as small arteries and veins densely
clustered, but in just proportions to one another. These are sucli as
maybe called " capillary;" understanding, only, that they probably affect
minute arteries and veins as well as capillaries. But, on the one hand,
deviating from these specimens, we find that in some cases the enlarge-
ment of arteries far exceeds, in proportion, that of the veins ; tlie swell-
ings pulsate, and are florid and over-warm, and, if injured, throw out
arterial blood. These constitute the " arterial " form of the disease : the
^aneurism by anastomosis." And, on the other hand, are tumors formed
mainly of dilated, sacculated, and overgrowing veins ; to these, arteries
of comparatively small size pass, while from them proceed very large
veins : and they are subject to changes of size in all the events that affect,
not the arterial, but the venous, part of the circulation.
Now, I believe that, in a majority of cases, the arterial and the venous
forms of the disease are constituted by a dilatation of large branches, of
one or the other kind, being superadded to such a condition of the small
vessels and capillaries as exists in the common, or " capillary " erectile
tumors. But I have, also, no doubt that, in rarer instances, arterial
• Med.-Chir. Trans^ vol. ix. p. 201, and pi. vi.
t Medical Gazette, vol. xxxvii. p. 1027.
J Northern Jotim. of Medicine. § Med.-Chir. Trans., vol. xxvi. p. 125.
I Pathologische Anatomie, i. 27G. IF Med.-Chir. Trans., vol. xxx. p. 193.
** What tissue may remain between the bloodvessels depends on tho sent of the na-vus.
The elements of the organ or tissue in which it has its sent will remain between its vessels,
wasted or altered by compression or defective mitrition. They are seldom present in any
distinct Ibrm ; but a case is well described by C. O. Weber, in which abundant fibrous nnd
fiitty tissue occupied the space between the dilated vessels of an erectile tumor in a child's
neck (MQller'8 Axchir, p. 74).
480 GAPILLART VASCULAR OB ERECTILB TTTMORB.
tumors arc formed by arteries alone, convoluted or anastomosing in t
heap, whence, as from an arterial ^' rete mirabile," i^ormal arteries pro-
ceed and lead to capillaries. And, on the other hand, there are, doubt-
less, venous tumors, which are formed of veins alone, and through which,
since they are seated altogether beyond capillaries, the blood passei
(according to Rokitansky's comparison) as it passes through a portal reiiL
Since few accounts of the minute characters of the erectile tumors han
been published, I will briefly describe those which I have examined, be-
ginning with an instance of the medium form, in a capillary subcntaneoni
naevus.*
A child, two years old, which had a naevus of this kind on the side of
the chest, died exceedingly emaciated after measles and diarrhoea. The
tumor had grown from birth-time, and had appeared as one of the most
ordinary subcutaneous naDvi or erectile tumors ; soft, compressible, dimly
blue as seen through the skin, swelling in forced expiration, thinly scarred
over its centre, in consequence of an ulcer which had spontaneously
formed and healed. After death it had shrunk into a very thin layer of
brownish tissue between the emaciated skin and the fascia covering the
serratus magnus. It was well defined, and could be dissected out cleanly
from the adjacent parts. Its surfaces and sections had a distinct lobolv
arrangement, many lobes projecting from its borders, and those within it
being separated by fibro-cellular partitions derived from the tough skin
and fascia between which the tumor lay. In its shrunken state, it most
resembled, in its obvious characters, a piece of parotid gland ; being pab
brown in color, lobulated, soft, but tough, and yielding but little blood on
pressure.
About six small collapsed veins proceeded, in a tortuous course, from
the surfaces and borders of the tumor. Its arteries were too small to be
distinct. Examined with the microscope, the whole mass appeared com-
posed of bloodvessels interlacing in fibro-cellular and elastic tissue, which
probably belonged to the natural subcutaneous structure. No parenchy-
mal cells or abnormal forms of tissue were found ; the disease seemed to
be of the bloodvessels exclusively.
The vessels, which were very diflBcult to extricate, in any length, from
the matted tissue about them, were of all sizes, from 5(/oif to ^Jq of iB
inch in diameter ; but I think none were larger. Nearly all of them were
cylindriform ; a few were unequal, or varicose, or sacculated, with small
pouches projecting from their walls (fig. 81). I could not discern their
arrangement ; but they did not appear to branch often ; neither am I
sure that they dificred in structure from the normal vessels of subcuta-
neous tissue, except in that they were, considering their size, of less com-
plex structure : they were as if minute vessels were enlarged without
acquiring the perfect form of those which they equalled in calibre. Id
* All the specimens described are in the Museum of St. Bartholomew's Hos>pii8l.
CAPILLABT VASCULAR OR ERECTILE TUMORS.
481
Pig. 81.»
\ '
I
\
I i V
y
/,
wme parts, I found long cords of fibro-cellular tissue, which, probably,
were obliterated bloodvessels.
I haye examined other tumors re-
aembling this, but in less favorable
eonditions. From all, however, as well
as from the descriptions of others, I be-
lieve the common structure of this form
of erectile tumor is a collection of
minute bloodvessels, dilated, and closely
arranged within a limited area of some
natural texture. In. the subcutaneous
tissue, arteries usually appear to pass
into the vascular mass from the under
mxrhce of the skin ; and veins radiate
from it, larger than the arteries and
more numerous, but scarcely exceeding
the proportion between the normal cuta-
neous veins and arteries. Within the
tmnor (which thus, as well by the relation
of its vessels as by their minuteness, justifies the epithet " capillary ") it is
probable that some of the vessels arc always sacculated or varicose. Vir-
diow*st account of this state exactly confirms what I have described ;
and, with more detail, RobinJ describes an erectile tumor in which, along
the track of the vessels, numerous little culs-de-sac existed, which the
Mood might be made at will to enter and quit, by alternately pressing
and letting-free a piece of the tumor on the field of the microscope.
These could be seen on vessels as small as 5 of a^illimetre in diameter ;
they wye generally smaller at their connexion with the vessels than at
their other ends, and were commonly twice as long as the vessels were
wide.
But although the vessels within the tumor be thus dilated, yet, as a
general rule, in this form of the disease, the dilatation (if there be any
in those proceeding to and from the tumor extends but a short distance
from it : the arteries enlarge (if at all) only just before they enter the
tumor; the veins regain their calibre soon after they leave it: and
hence the general safety with which John Bell and many others have cut
out such tumors, when they attended to the rule he lays down with such
emphatic repetition, that in treating such a tumor we are ^^ not to cut
into it, but to cut it out." However, this limitation of enlargement to
the vessels within and near the tumor, is not so usually observed in the
next two forms of the disease, as in this which I have just described.
* Bloodvessels of the erectile tumor described in the text,
t Archiv. ftkr Pathol. Anatomie, B. iii. p. 437.
X In Lebert ; Physiologic Pathologiqae, t ii. p. 99.
81
Magnified about 200 times.
482 ARTERIAL VASCULAR TUMOBS.
The best example of the arterial erectile tumor, that I have been able
to examine, was from a man who died under the influence of chloroform
at St. Bartholomew's Hospital. He was 23 years old, and the diaeue
occupied the external ear, the adjacent subcutaneous tissues, and part of
the scalp. The back of the auricle, in nearly the whole extent, mi
puffed out by a superficially lobed, soft, easily compressed, and elastic
swelling, which all pulsated fully and softly. Two similar and continiiou8
lobes of swelling were under the scalp above and behind the auricle ;
and these were well-defined above, but gradually subsided below. The
skin covering the swelling was for the most part dusky-purple, but,
except where it was scarred, appeared of healthy texture ; the skin of
the interior of the auricle and its fibro-cartilage also appeared unaffected,
except in the turgescence of the bloodvessels. A posterior branch of
the superficial temporal artery passing by the front of the swelling, and
a branch of the posterior auricular artery passing behind it, felt large,
and pulsated strongly : the common carotid artery, also, on this side,
pulsated more fully than that on the other. A distinct soft' bruit wiA
audible, synchronous with the pulsation in the tumor ; and distinct pul-
satile movement was visible.
This disease had been noticed like a very small pimple when the
patient was four years old. It had from that time regularly increased.
On four occasions severe bleeding had taken place from it, through tn
ulcer in the skin over it, or through a prominent part over which the
skin was extremely thin. After the first of these bleedings a piece of
the swelling had been tied, and had sloughed away. A month before
the patient's death, Mr. Lloyd had tied and compressed the branch of the
temporal artery and two other principal arterial branches at the borders
of the swelling ; and by this and subsequent treatment had diminished
the size of the tumor and the fulness of the pulsation in and around it.
Much of the tumor had been spoiled by this treatment, but enough
remained to show that a great part of its substance was like that last
described, and probably, like it, consisted of minute bloodvessels col-
lected in a soft spongy mass. But, while the veins proceeding from the
swelling were of no considerable size, the arteries passing to it and
within it were very large, convoluted, and thin-walled. This was espe-
cially observed in the posterior auricular artery, which had not been
interfered with in the operations. A lobe of the swelling (as it seemed)
had pulsated strongly below and behind the lobule of the ear ; and it
was for the operation of tying this that the chloroform was given to the
patient. This proved to be only a part of the posterior auricular artery,
which, from a short distance beyond its origin, was large, and more col-
lapsed and flattened than the other branches of the external carotid.
At the beginning of its enlarged part, this artery was from a line to a
line and a half in diameter ; and from this point its trunk, as well as
its branches (which were not unnatural in either number or anastomosis),
ABTBRIAL VASCULAR TUMORS. 488
were tortaous and coiled up in heaps, which had felt during life like pul-
Biting masses. The dilatation of the arteries was uniform, not saccu-
lated, though in parts the suddenness of the curves made it appear so.
The small intervals between them were filled either with the natural
fibro-cellnlar tissue, or with the minute bloodvessels that composed the
chief mass of the tnmor.
I believe that this specimen presented a fair example of the ordinary
stmctare of the arterial form of vascular or erectile tumors ; and that
they consist, essentially, of the minute vessels of a limited portion of
tissue enlarged and closely clustered, so as to form a tumor, in the sub-
stance, as well as about the borders, of which are arteries much more
enlarged, and convoluted into pulsating heaps.
The existence, and even the preponderance, of the minute vessels in
such tumors was manifest in a specimen sent to mc by Dr. Ormerod.
A healthy woman, about 60 years old, had for many years a pendulous
growth in the lower and inner part of the left axilla. Lately it had
grown quickly to the size of the closed hand. It was dark, hard, and
knotty, with a distinct pulsation, and hung on a pedicle in wliich a large
artery could be felt. A ligature was tied on the pedicle, and a few hours
tfier another was applied, and the pedicle was cut through.
The tumor was gorged with blood, ecchymosed, and too much damaged
for complete examination. Its general aspect was like that of the
pedicled outgrowths of skin; but nearly its whole mass consisted of
minute bloodvessels confusedly arranged and of various sizes. Their
walls showed nuclei, which were generally shorter than those of healthy
arteries : but in many instances were placed, as in them, regularly in
layers, the external lying longitudinally, others within these transversely,
and, still within these, others that were obliquely or variously placed.
Besides the bloodvessels, I could find in the tumor only a comparatively
small quantity of fibro-cellular tissue ; and Dr. Ormerod*s examinations,
made when the tumor was more recent, had similar results.
Some, I think, have described the arterial tumors as formed by the
convolutions of a single artery ; and the characters of the swelling
formed by the trunk and commencing branches of the posterior auricular
artery, in the first of these cases, make me ready to believe that this
description may be sometimes true. But I think that, more commonly,
many branches of arteries are engaged in the tumor. Such was the
case in the tumor of the ear, and in an instance recorded by Mr. Coote.*
Arteries of the lip, which, in their natural state, might not have had a
greater diameter than a large pin, were dilated for about an inch of their
course into sinuses or canals, and were equal in diameter to the adult
radial artery. Similar to this was a very formidable case, cured by com-
pression, under the care of Mr. Lloyd. The temporal, supraorbital, and
occipital arteries, all exceedingly dilated and tortuous, converged to a
* Medical Gazette, vol. xlv.
484 VENOUS VASCULAR TUM0B8.
large pulsating swelling over the sagittal suture, the general characten
of which agreed exactly with what I have described.
In the arterial vascular tumors the veins are comparatively small; and
the difficulty of transit for the abundant blood flowing into them, doubt-
less adds materially to the fulness of the tumors, and of the pulsations seen
and felt in them. In the venous tumors the opposite condition obtains;
the veins are very large, the arteries comparatively small. Of this kind
of tumor the following case presented a good example.
A man, 32 years old, was under the care of Mr. Lawrence. He hid
a hoof-shaped tumor projecting from the middle of the outer part of his
thigh. It was from six to eight inches in diameter, and looked like some
strange outgrowth of skin. Its base rested on the fascia lata ; it was
covered with skin, which was healthy, except in one excoriated place, and
adhered closely to it. It was firm, but compressible and elastic, and by
long-continued pressure could be reduced to nearly half its size, as if by
squeezing blood from it. Several small arteries pulsated at its base ; and
very large veins, like tortuous sinuses, converged from it towards the
upper part of the saphcna vein.
The patient was in feeble health, apparently through the effects of a
life in India, where, in the army, he had received a wound by a musket-
ball, to which he referred as the cause of the growth of this tumor.
Before the wound, he believed the part was quite healthy. The injury
appeared superficial, and he was absent from duty only two days ; but, six
months afterwards, he observed a small tumor, and this, growing con-
stantly and with severe pain, had increased in ten years to the present
mass. The skin had been slightly ulcerated for twelve months, and
severe hemorrhages had occurred from the ulcerated part, reducing hifi
already diminished strength.
Mr. Lawrence cut away the whole tumor. Its connexions were slight,
except to the skin covering it ; the arteries at its base bled freely, but for
a short time ; the great veins bled very little.
A section through the tumor showed that, while some parts of it ap-
peared solid and close-textured, like a mass of firm fibro-cellular tissue,
the greater part was like the firmest cavernous, or erectile tissue.
Sections of bloodvessels, of various sizes and in various directions, were
so thick-set, that the surface loked all reticulated and grooved with them.
The general color of the tumor, which seemed to have almost emptied
itself of blood during the operation, was nearly white ; but in some parts
it had a pale ruddy tinge, and in a few was blotched with small rusty
and ochry spots.
The microscopic examination was less instructive than the general
aspect of the tumor. Its tissue was very hard to dissect, and displayed
(as its chief constituent) matted and crooked fibres, like those of close-
textured longitudinally striated membrane of bloodvessels, with shrivelled
BBECTILE OB VASCULAB TUHOBS. 485
iraclei imbedded in membrane, some of these nuclei being round, some
oral, and some very narrow and elongated. I think the obscurity of the
microscopic appearances was due to the tenacity with whicli the blood-
Tessels were imbedded in the elastic fibrous or nucleated tissue ; it seemed
impossible to extricate complete vessels ; and one obtained by dissection
only fragments of their walls confused with the intermediate tissues.
Other cases of venous nsevi, which I have been able to examine less
completely, have confirmed the foregoing account, especially in regard
to the small size of the arteries in comparison with the veins, the generally
dilated and varicose state of the latter, and the imitation of the characters
of erectile tissue, which appears always more marked in the venous than
in the other forms of vascular tumors.
Such are the principal facts that I can cite regarding the structure of
Ae vascular or erectile tumors. They are very meagre, and much is left
for future inquirers;, especially the manner in which the larger vessels
are connected with those smaller ones which, in most cases, make up a
chief part of the swelling; and the changes of structure, if any, which
exist in the proper tissues of the walls of the bloodvessels. Still, from
eren these few facts, some general considerations may be derived.
That which is common to all the vascular or erectile tumors is an over-
extension of bloodvessels or bloodspaccs within a circumscribed area.
Their chief varieties depend (1) on the kind of vessels affected, and (2)
on the nature of the tissue in which these vessels lie. The varieties of
the first class have been pointed out ; but all of them alike present the
singular instance of the apparent primary growth of bloodvessels. In
all other tumors, as in all abnormal products, the formation of blood-
vessels appears to be a consequent and subordinate process. As in the
natural development of parts, so in what is morbid, organization to a
certain point precedes vascularity, and the formation of bloodvessels
follows on that of the growths into which they pass. But here the case
appears reversed. The calibre of the bloodvessels increases and the
solid tissues between them diminish ; all the growth of an erectile tumor
is an enlargement of bloodvessels, with diminution of the tissues in which
they ramify; or, rather, it is often an enlargement, not of bloodvessels,
but of blood-spaces : for though, in the first stages of the disease, the
walls of the vessels may grow, and elongate, so that the vessels become
tortuous, yet, after a time, the walls waste rather than grow ; apertures
seem to form through mutually apposed bloodvessels, and at length,
while the blood within the tumor increases, the bloodvessels containing
it diminish, together with the parts in which they ramified. Hence, at
last, in place of branching and anastomosing tubes, there is only a net-
work formed of the remains of their walls. This is an increase of
blood-spaces rather than of bloodvessels ; so far as solid tissue is con-
cerned, we might call it a wasting, rather than a growth ; no new materials
486 OENEBAL CHABA0TBR8 OT
seem to be added, but step by step the bloodreasels are dilated^ and tha
intervening tissues clear away, leaving room for more and more blood.
Such a fact constitutes a great contrast between these and any other
diseases named tumors. And yet perhaps we may properly regard then
as being overgrowths of bloodvessels, comparable with the overgrowths
of the various other tissues illustrated in the preceding chapters. And
their relation to such overgrowths seems, sometimes, distinctly proved in
the gradations of morbid changes that connect them with mere enlargement
of bloodvessels. If we examine different specimens of these tmnors, or
sometimes even the condition of the vessels adjacent to one of them, we
may observe a regular gradation from the erectile tumor, through clusters
of dilated and tortuous vessels, to that which we regard as merely the
varicose condition of the veins or arteries. Such transitioDB are well
shown in some of Gruveilhier's plates, and in a remarkable case by Dr.
Hake and Mr. Image ;* as well as in two of the cases that I have related
In relation to the tissues in which this overgrowth of bloodvessels may
take place, we may hold that there are two chief classes of cases. In
some the vessels of a natural part are affected ; in others the vessels of a
new growth. In the former class, I think, are the greater part of the
common erectile tumors of the skin, and of the other parts in which they
are most frequently seated ; as the muscles,t the bones,]; the orbit, and
the liver. In these the remains of natural tissues may be found in the
interstices of the bloodvessels, and, either in or near the tumor, well-
known arteries or veins are involved. In the latter class, examples of
which have been cited in the tumors on the side (p. 483) and on the
thigh (p. 484), the bloodvessels of new-formed parts are affected. To
this class, also, may bo referred, I think, the florid and highly vascular
growths that are frequent at the orifice of the female urethra,§ and per-
haps many others. ||
As I liave hitherto chiefly had in view the subcutaneous erectile
- ♦ MedicoChirurgical Transactions, vol. xxx. p. 109.
t See especially a case by Mr. Liston, Med. Chir. Trans, xxvi. 120 ; and one by Mr.
Cootc, 1. c. ; and Cniveilbier, livr. xxx. pi. 5.
j: Amon^ these may be included, probably, some of the cases described under the name
of Aneurism of Bono and Ostco-Ancurism ; as by Dr. Handyside, *' Probationary Surgical
Essay,-' Breschct, and others. But I am fur from convinced that, in all the cases thus en-
titled, the bloodvessels of the bone were primarily or chiefly diseased. My impression is
that, in many of them, the disease was really medullary cancer of the bone Mrith excetsiTe
development of vessels, and that, in some, it was such a blood-cyst as appears to be some*
times formed in the cour.se of a myeloid or cancerous disease.
§ The specimens of these growtlis which I have examined have displayed a very abon-
dant and tessellated epithelium covering a small quantity of fibro-cellular ti«sue, with close-
set and looped bloodvessels. They might bo regarded as warts with excessive formatioD
of vessels.
II While this sheet was being printed I received Rokitansky's essay " Ucber die Ent-
wickelung der KrebsgerOste,'^ including his most recent account of the fbrmRtion of the
erectile or cavernous structure of tumors. I shall refer to it in the descripticm of the fifauneii-
tous tissue or skeleton of lueduVlaty cancers in the 31st lecture.
BBBCTLLB OR VASCULAR TUMORS. 487
tumors or nsevi, so I will now, in describing the general characters of the
disease, refer to them alone for examples. Even of these, indeed, it is
difficult to give a general account, since we can make only an artificial
distinction between such as may bear this name, and those extended
dilatations of cutaneous vessels, which with little or no swelling, form the
cutaneous nsevi, port-wine-spots, and the like. These are, evidently,
essentially the same disease ; the terms, cutaneous and subcutaneous
nsevi, respectively applied to them, imply only their diiference of seat ;
they have no real difference of nature, and are very often associated.
But, if we include only such as are for the most part or wholly subcutaneous,
then it may be said that they are generally round or oval, disk-shaped,
or spheroidal, but are often ill-defined, the morbid state of the blood-
vessels in which they consist gradually merging into the healthy state of
those beyond them. Sometimes, and especially those of most venous
character and of longest duration, the mass is circumscribed by fibro-
eellular tissue, which forms a kind of capsule, is penetrated by the
bloodvessels passing to and from the tumor, and is very intimately con-
nected both with the surrounding parts and with the tumor.
The vascular tumors are remarkable by their frequent beginning before
iHTth, and their especially quick growth in early childhood. Beyond all
comparison they are the most common of congenital tumors. Hence,
mother-spot is almost synonymous with nscvus, and nscvus with erectile
tamor. But they may begin, or accelerate their growth, at any period
of life. I have seen one of which no trace existed till the patient was
twenty-five years old ; and another in which the rapid growth began, for
the first time, when the patient was past fifty. Dr. Warren mentions a
case of erectile pulsating tumor about the angles of the eyes and the fore-
head, which began in a girl seventeen years old. Many others, no doubt,
have seen similar cases.
Their origin is generally unknown ; but, as one of the cases I have
related shows, they may commence in the results of injury ; or, rather, a
tumor may originate in injury, and in this tumor an exceeding formation
of bloodvessels may ensue.
Their growth is uncertain ; they may seem at rest for many weeks
after birth, and then grow quickly, and then again may stay their
growth : and having attained a certain size, may remain therein limited,
or may decrease or disappear, the vessels, in whose enlargement the
growth consisted, regaining their natural calibre or becoming obliterated.
Their maintenance of life, if I may so term it, is not strong. They
are much more apt than the natural tissues are to slough or ulcerate after
injury; and, in general disturbances of the health, they may perish
altogether. I know a case in which a large subcutaneous mcvus in a
child*s forehead sloughed, while another on its back, of much less size,
was in process of sloughing after the application of nitric acid. Similar
apparently spontaneous sloughings have occurred during, or in the debility
488 GBNEBAL CHARACTERS OF SRBCTILX TTIIOES.
following measles or scarlatina. Such events may be connecte*! wjri ^
extreme slowness of the movement of blood in the tumors : finr tintf^
they contain abundant blood, they probably transmit it very riovljf^
Venous tumors not unfrequently contain clots of blood and phleKtlitkifl J
such, probably, as would form only where the circulation is mr*t «Wt f
and even in the arterial tumors the full pulsation seems t« indicate i|
retarded stream.
The diseases of the vascular tumors are of much interest : espeviaBf
two amongst them, — ^namely, the formation of cysts, and that of malismul
structures in their substance.
I just referred to the formation of cysts in erectile tumors, vki
speaking, in the second lecture (p. 341), of serous cystd in the neclu uii
of sanguineous cysts. The history of the changes by which an erectii
tumor becomes in part or wholly cystic is very incomplete: for tli
opportunities of observing them, except when they are accomplished, in
rare. The principal facts are, that, next to the erectile tumors tboM
that are composed of clusters of serous or sanguineous cysts appear tob
the most common congenital form, and that in some cases the two fom
appear in one mass. I referred, in the second lecture (p. 341). to »sk
a case as recorded by Mr. Coote. Mr. Caesar Hawkins,'^ also, had brfoif
described similar cases. He says of one, '^ You may see, in ailditi<H) »
the usual vessels, that several apparent cells exist. Some of ilwMr »ef«
filled with coagulum ; their structure appeared identical with thr •tber
veins, of which they constituted, as it were, aneurismal pouches ....
There were, however, besides these, some other cysts, wliich i*i»iii.ii:.t-'i
only serous fluid, and which were, to all appearance, close-shut sac-
serous cyst.s — their size bein^^ about that of peas.'*
In other instances, no erectile or ntvvous structure can be fnun-l. !«
the communication oxistin^j betwoen one or more amonj: a dii-t'T -f
cysts and some lar^o bloodvessel, makes it probable that tlu-y iia>i :be
same origin. Tlius, Mr. Coote traced a vein, as large as a radial vris.
openin;z: into the cavity of a cyst, which formecl one of a lar;re ok-w
removed by Mr. Lawrence from a boy's si<le. The mass formed bTt!:»*e
cysts had existed from birth ; some of them containetl a serous fiuii
others a more bloody fluid. In another similar clusterf removed fp^in •
boy's groin, one cyst appearetl to communicate with the femoral vein, or
with the saphena at its junction with the femoral. In one casi- miO-
tioned by Mr. IIawkins,J when a cyst in the neck was opene<l, arteriil
blood gushed out. In another, the 'patient died with re|>eated henj'^-
rhages from a cyst in the neck, and this cyst was found after death to he
one of several, in some of which the bloodvessels of the isthmus of the
thyroid gland opened.
It is difllicult to interpret the formation of such cysts in n«vi. or is
* Mcdk*o-Ciiirur{;icnl Trnn.»<i<rtion.s vol. xxii. ; iiiu! Medical Gn/etip, vol xuviL p. I--'
'f Tlie ypef'iiiicii U in the MiiJM'uin (if St. Bartholomew's lI(K>|iital.
^Clinical Lectures, in the Medical Gazette, vol. xxviii. p. 838.
8CIBRH0US OR HARD CANCER. 489
ecnmezioB with them or with veins. It may be that, as Mr. Hawkins
believos, cystB are formed in these, as they may be in many other tmnors,
and that gradually, by the absorption produced by mutual pressure, they
are opened into communication with one or more of the veins, or of the
sacs connected with the veins. Or, as Mr. Goote suggests, it may be
that certain of the dilatations of the vessels arc gradually shut off from
the stream of blood, so as to form shut sacs ; and that after this their
contained blood is absorbed, and replaced by serous fluid.
Lastly, respecting the production of cancerous disease in the tissue of
erectile tumors, it seems to be generally regarded as a frequent event,
and these are commonly believed to afford the most frequent instances of
malignant growths supervening on such as were previously innocent. I
will not doubt that such events have happened. In one case recorded by
Mr. Phillips,* the transition appears to be very clearly traced. Yet, I
think that in many of the cases which have gained for erectile tumors their
ill repute, a clearer examination would have proved that they were, from
the beginning, very vascular medullary cancers, or else medullary can-
cers in which blood-cysts were abundantly formed. Or, it may be that
the erectile tumors have been presumed to be liable to cancer, through
h|k?ing been supposed to share in .the peculiar liability of the pigmentary
Dsevi, or moles, to be the seats of melanosis.
LECTURE XXX.
SOIRRUOUS OR HARD CANCER.
PART I.— ANATOMY.
The foregoing lectures have comprised the histories of the Innocent
Tumors ; and in the first of them I related the characters generally
appertaining to the Malignant Tumors or Cancers, which it now re-
mains to describe.
For an account of this class of tumors it will, I hope, suffice if, after
reference to the twenty-first lecture, I describe, in order, each of the chief
forms in which cancers occur, and then gather such conclusions as may be
drawn respecting the general pathology of the whole class, and the re-
lations of the several forms to each other, and to other tumors.
The chief forms of cancer are named severally Scirrhous, Medullary,
Epithelial, Colloid, Osteoid, Melanotic, Villous, and Ilsematoid. These,
at least, are the names most frequently applied to them. The degrees
of difference between the diseases to which they are severally applied are
* On Vaaoular Tumors, in the Medical Gazette, vol. xii. p. 10.
490 ANATOMY or THB SCIBBH0U8 OB
not nearly equal ; and, probably, under certain of them^ two or more
diseases are included, which are sufiSciently different to justify their sepv
ration with distinct names. But Ihese are points which, having jut
mentioned, I may leave to be discussed in the account of each form of
cancer, or in the concluding lectures.
First, I will speak of Scirrhous or Hard Cancer.
Being both more frequent and more obvious than any other form oC
cancer, this was, to the beginning of the present century, the type and
chief example of the disease ; and so, in regard to its physiology, and
many particulars of its structure, it may still remain. It has received
many names, "*" such as scirrhus, scirrhoma, and others, expressing that
hardness of texture which is its distinctive and especial characteristic;
or such as Carcinoma reticulare, implying certain minute peculiarities rf
structure. I believe, however, that these peculiarities are too inconstant
and accidental to justify the division that they suggest : I wiU therefore
include them all under the name of Scirrhous or Hard Cancer, and will
use these terms for all stages of the disease, avoiding that which seems
always a confusing distinction, in which, before ulceration, the disease is
called Scirrhus, and after it. Cancer.
I will describe the Scirrhous cancer i^rst, as it occurs in the breast, be-
cause here the disease is far more frequent than in any other part, and
presents, openly, most of its varieties of appearance according to its sno-
cessive stages, and the accidents to which it is exposed.
The scirrhous or hard cancers in the breast are very far from being so
uniform that they may be briefly described. I believe that they are al-
ways primary cancers ; always infiltrations ; and almost always seated,
in the first instance, in some part of the mammary gland ; but, when we
compare their other characters in any large number of specimens, we find
in them many and great diversities. Probably, therefore, it will be best if
I describe first and chiefly the ordinary characters of the disease ; the form
in which it is most frequently seen, when it has not been changed by
softening, ulceration, or any other morbid process. I can then add to
this description, by way of comparisons, some accounts of the principal
deviations from the more usual form ; and, in the next part of the lecture,
can give the history of the changes that ensue in the progress of hard
cancers towards destruction, or in their much rarer regress.
Most frequently, the scirrhous cancer of the breast Appears as a hard
mass occupying the place of the mammary gland, or of some portion of
it. In the cases I have collected it has not been more frequent in one
breast than in the other. It is least frequent at or near the inner mar-
gin of the mammary gland ; but with this reservation, it is not more fre-
quent in one than in another part of the gland, or in any part than in
the whole.
* Enumerated by Dr. Walshe : On Cancer, p. 10.
EABD OAirOEB OF THE BKBABT.
491
While part of the glsod in cancerous, the rest is, oommonl;, healthy ;
Int, according to the age and oondition of the patient, it maj be more
or lees atrophied and withered ; or excess of fat may be accumulated
roand it; or it may contiun numerons email cysts, oae or more large
cysts most confnsing to the diagnoeis; or, more rarely, it may be the
seat of mammary glandular tumor (p. 473), or of some morbid change
of Btructnre. As yet, however, I believe no connexion can be traced be-
tween any of these conditions and the growth of cancer, unless it be that
it is peculiarly apt to happen in breasts that are being defectively
nourished.
The hardness of the cancer, as compared with that of other tumors, is in
most cases extreme : it is about equal to that of a lump of fibrous carti-
lage, and is associated with a corresponding rigidity, weight, and ine-
lasticity. Cases, however, ore not unfrequent, especially when the cancer
grows quickly, in which the mass is less hard — very firm rather than
hard — about as flexible and elastic as the body of an unimpregnated
uterus.
The sise of a hard cancer is seldom very great, in most cases, it is
rather smaller than the y.^^ ^^
part of the gland which
it occupies was in the
healthy state ; so that,
&jr- if half a mammary
gland become cancerous,
■nd half remain healthy,
the latter may bo two or
three times larger thou
the former; or, if the
whole gland become can-
cerous, it may be reduced to less than half its natural size. The ex-
ceptions to this diminution
in the size of the cancerous "•" "^^
fl^nd are, I believe, in
cases of very rapid growth,
in which the caneer-matc-
rial seems to be added
more rapidly than the
materials of the gland can
be removed.
The shape of the hard cancer, also, depends chiefly o
gland that it affects. Generally, it mn^ be said that when the cancer does
not extend beyond the limits of the gland, it doca not much deviate from
the shape of the affected part ; only, it gathers-up, aa it were, the gland-
n the part of the
■ Fig. B2. SectioD of a hani cancer, exlen<liiig frot
10 ihf iuperiBcent Bkin, and nffecting UHh llie?e one!
t V>i- 63. Section of a haid cancer at a wliole m
a border-lobe of tlio mBmrnar; fi[iioA
; interveniiiB tissue!. Niuunil sii^e.
imory gland. Half the natural v.za.
492 ANATOMY OF THE SOIRRHOUB OB
lobes into an irregular lump, in which their outline is not lost, but blunted.
Hence, according to their seats, we may observe diflferent shapes of hwd
cancers of the breast. At the anterior surface of the gland it is ustuUy
convex or obliquely shehdng ; at the posterior surface it is flat or slightly,
concave, resting on the pectoral muscle ; in the middle, or thick substance,
of the gland, it is commonly rounded and coarsely tuberous, knotted, or
branched ; at the borders it is often discoid, or else is peculiarly apt to
extend from them in a mass reaching to the adjacent skin (fig. 82) ; and
when the whole gland is affected, the cancer has commonly a low conical
shape, or is limpet-shaped, with the nipple set on the top of the cone
(fig. 83).*
From any such cancerous lump, processes, like crooked, gnarled, and
knotted branches, may extend outwards, in correspondence with the out-
lying lobes or processes of the gland. But shapes like these are com-
paratively rare ; and scarcely less so are the instances in which portions
of the gland, after becoming cancerous, are detached from the chief
mass ; or those in which, in the same gland, more than one cancer forms
at the same time. Such cases do, however, happen ; and I have known
the smaller detached cancers nearly escape removal in operations.
As we dissect towards the surface of a hard cancer, especially of one
of which the growth is not very rapid, we may observe that relation of
the tissues around it which is so characteristic ; I mean, their contraction
towards it, and their progressive absorption. It is as if, in its progress,
the cancer were always growing more and more dense, by the contrac-
tion and compacting of its substance, and by the absorption of the tissues
it involves ; and as if, in this concentric contraction, it drew all parts
towards itself. To this it is due, that, even from the first, and when it
is yet very small, a hard cancer in the breast feels as if it could only be
moved with the gland around it ; it does not slide or roll under the finger
as a mammary glandular tumor does. To this, also, is due the slight
dimpling of the skin over the nearest adjacent part of the cancer, even
long before the two have become adherent ; and to this we must ascribe
the more numerous depressions, seaming and wrinkling the surface of the
breast, and making it appear lobed, when, in a case of cancer occupying
the whole of a large and fat breast, many parts of the skin are drawn
inwards. To the continuance of this contraction and absorption, also,
are due the sinking-down of the retracted nipple, and the uplifting of
the superficial fibres of the great pectoral muscle ; and then, the deeper
furrowing and the adhesion of the sunken skin or nipple, and the firm
conjunction of the pectoral muscle with the deepest portion of the cancer.
• The terms " ramose," " tuberous," and " infiltrated," have been applied to specify the
hard cancers, according to their shapes; but at present the shape appears so little connected
with any other character of the disease, — it seems so nearly accidental, — that it cannot well
be adopted for a ground of specific appellation. Moreover, there is no reason for especially
calling the cancers that afiect the whole gland, infiltrated • for all the hard cancers of the
breast are infiltrations in less or more of its structure.
HARD OANOEB OF THE BBEA6T. 498
Sometimes one finds bands of tough tissue extending from the retracted
parts of the skin to the surface of the cancer. These are commonly
supposed to be always cancerous, — "claws," or outrunners from the
cancer ; but the supposition is only sometimes true ; they often consist
of only the cellular tissue between the lobes of the subcutaneous fat,
condensed and hardened.
A scirrhous cancer in the breast has no distinct or separable capsule
of cellular tissue investing it : the proper tissues of the breast, that are
in contact with its surface, adhere to it very intimately ; and the more
80, the more slowly it has grown. The general boundary between them
is, indeed, distinct to the sight ; yet it is not easy to dissect out the can-
cer ; and, at certain parts, it is evident that the tissues around the cancer
ire continuous witl^ some of those within it. Especially, we can often
see that the lactiferous ducts pass, from the nipple, or some healthy
portion of the gland, right into the substance of the cancer.
When we cut through an ordinary hard cancer of the breast, such as
I am chiefly describing, the surface of the section becomes at once, or in
a few minutes, slightly concave. This is a very characteristic appear-
ance, though not a constant one : I know no other tumor that presents it.
In all others, I think, the surface of the section either rises, and becomes
dightly convex, especially at its borders, or remains exactly level. In
well-marked hard cancer the cut surface becomes concave, sinking in to-
wards its centre, through the persistence, I suppose, of that tendency to
contraction, to which, during life, we have to ascribe the traction of the
surrounding tissues, and which is now no longer resisted by them.
The cancer seldom appears, on its cut surface, divided into lobes : it is
one mass, variously marked perhaps, but not partitioned ; neither has it
any distinct grain or fibrous plan of structure ; its toughness and tena-
city are complete, and in every direction equal. It has, generally, a
pale grayish color, and is glossy, and half-translucent ; often it is slightly
tinged with a dim purple hue, or, in acute cases, may be more deeply
and more darkly suifuscd. Very often, too, its grayish basis is marked
with brighter whitish lines, like interlacing bundles of short straight
fibres, and with minuter ochre-yellow lines, or small yellow spots, and
with various transverse and oblique sections of duets.
The explanation of these various appearances, and of the minuter
characters of the cancer, can be understood only by recollecting (what
all the foregoing description will have implied), that the cancerous mass
is composed not only of structures proper to the cancer, but of more or
less of the tissues of the mammary gland, or other parts, among which
the cancer-structures are inserted. And the differences implied in the
words " more or less," may be considered as explaining many of the
differences of appearances that hard cancers present.
The consideration of the influence of cancer-formations on the tissues
that they occupy belongs, more properly, to the general pathology of the
disease ; but I must here just refer to the main facts concerning it.
494 CONDITION OF THE TISSUB8 INyOLYBD.
r
As I have said, the formation of a scirrhous cancer of the breaat eon-
sists in the production of peculiar structures— oancer-oells and othen—
in the interstices of the proper tissue of the part (see fig. 84, p. 496).
Yirchow* has fairly likened it, so far as the relation of the new and old •
materials is concerned, to the condition of pneumonia in a lobule of the
lung, in which the lymph is deposited among the natural textures, so u
to be thoroughly mixed up with them, and to form one mass with them.
Thus, then, we have, in any such cancer of the breast, a mixture of
cancer-substance and breast-substance. But among many cancers we
should find many diversities in the proportions of these two substances;
which diversities are determined, first, by the original proportions in
which the two substances are mingled ; and, secondly, by the degrees of
wasting, and other changes, that may occur in either or both of them.
For example, a large quantity of cancer-substance may occupy so small
a portion of the gland, that this portion, spread out as it is in the sub-
stance of the cancer, may be scarcely discernible, and the cancer may
look like a completely isolated tumor ; or, on the other hand, the whole
of an atrophied gland may be condensed within a comparatively small
cancer.
Moreover, after the original proportions of the two substances are
determined, they may not remain the same ; for their subsequent propo^
tions of increase or of decrease may be different. Generally, as tlie
cancer- substance increases, so the involved structures of the breast dimi-
nish or become degenerate, till they can hardly be recognised, and the
cancer is where the natural structure was : a complete " substitution," aa
M. Lebert names it, is thus accomplished. But the original tissues do
not thus disappear at any given rate, or all in the same rat« or order.
The gland-lobules, I think, waste very early : I have never found them
clearly marked within a hard cancer. The larger gland-ducts remain
much longer ; their cut orifices may be often seen on the section of the
cancer, or they may be traced right into it from the nipple, or fragments
of them may be found in microscopic examinations. The small gland-
ducts, with their contents, often appear, in branching bufi* and yellow-
ochre lines, imbedded in the substance of the cancer. The fat of the
breast is commonly quickly wasted : we find sometimes portions of it
encircled by the cancer, and sometimes its yellow tinge is diffused through
parts of the cancer, as if they were thoroughly mingled : but both these
appearances are limited to the superficial and more lately formed por-
tions of the growth : they are always lost in the central and older parts.
There is the same gradual disappearance of the elements of the skin
when it is involved ; so that we might say that the regular process in the
formation of a cancer of the breast is, that, as the cancer-substance in-
creases, so the natural tissues involved by it degenerate and waste. I
repeat, we might say this, if it were not for the fibrous tissue that inter-
* In his Arcbiv, B. i. p. 05.
^^canoeb-juioe" and "stroma." 495
TeneB among the lobes and ducts of the gland ; for this seems either to
waste more slowly than any other part, or to remain unchanged, or even
in some cases to increase with the progress of the cancer. To these
conditions of the fibrous tissue I shall again refer.
Now, if to the progressive yarietics that may arise, through these
ehanges in the involyed tissues of the breast, we add that parts of the
proper cancer-substance may degenerate or waste, or may vary in their
method of development, while other parts are merely increasing, we may
apprehend, in some measure, the meaning of those great varieties of
appearance which we find in any large series of cancers. They are
mainly due to the different modes and measures in which the constituents
of the cancer-substance and of the original tissues are, first, mingled
together, and then increased, degenerated, or absorbed.
After this necessary explanation, let me return to the description of
the mingled mass. We find, as I have said, in any ordinary cancer of
the breast, a grayish basis, which contains the proper elements of the
cancer, but which is or may be intersected by visible fibres, ducts, and
jellow lines or spots, which belong chiefly, or entirely, to the textures
of the breast. One may usually press or scrape, from the cut surface
of such a cancer, a pale grayish, thick, and turbid fluid, which is easily
diffused through water, and is much more abundantly yielded, when the
cancer has been macerated for a day or two in water. It is not creamy,
but rather like thick gruel, and is usually composed of a mixture of the
proper cancer-substance, and of the softened tissues of the breast, and
the contents of the bloodvessels and remaining gland-ducts. It is called
the " Cancer-Juice," and what is left after it is expressed, is called the
" Stroma" of the cancer (see, further, p. 601). I should state, however,
that about the central and deeper parts, or sometimes in the whole masses
of the hardest cancers, no such fluid can be obtained ; they yield to
pressure or scraping, only a small quantity of yellowish fluid, like turbid
serum.
The remaining description of the hard cancer must be, chiefly, from
its microscopic appearances.
In very thin sections it is not difficult to see the infiltration, or inser-
tion, of the cancer-substance in the interstices of the affected tis-
sues. It may be most clearly seen in sections of any part of the skin
recently invaded by the cancer, for here, in the meshes of the reticulated
fibro-cellular and elastic tissues, the caucer-particles are quite distinct,
filling every interval, and not obscured by the ddbris of the gland-ducts
and their contents. I am not aware of any more orderly plan of arrange-
ment of the materials of the cancer than that which may be expressed
by saying that they fill the interstices of whatever tissue they may lie
in. They may either expand these interstices, when they accumulate
quickly and abundantly; or, when they shrivel and degenerate, they
may iJlow the tissues to collapse or contract.
496
KICBOBOOPIC AHArrOltX OF
The elementary Btnictures of the cancer-HubBt&nce, thoa infiltrated ii
tke breast, are chiefly two : namely (1), certain cells and other corpw-
cles ; and (2), a. fluid qr solid blutemi, <s
nearly homogeneous substance, in vludi
these lie imbedded. We may study these,
but, it must be admitted, in some confosiM
and uncertainty, in the material obtuned
by the pressure from the cancer.
The blastema, or intercellular substance,
presents, I believe, no peculiar featnres-f
As obtained by presBure, it is made tnj
impure by the admixture of blood ud
other fluids ; and it would be unsafe to
dcBcribe it more minutely than as a pellu-
cid or dimly granular substance, which in certain cases, yet I think rarely,
assumes an appearance of fibrous texture. The corpuscles of hard
cancer are chiefly nucleated cells. In ordinary cases, and where the
cancer has not been deflected from its normal course, their characten
are constant and peculiar, and may be described as for the types of
" fig. 85.
In shape they are variouB. Usually a large majority are broadly oval,
or nearly round : in some specimens, indeed, all may have these forms;
but, in other Bpecimens, though these prevail, yet many cells hare one
or more angles, or outdrawn processes, and some are pyrifonn, some
fusiform, some reniform, some nearly lanceolate.
It would bo useless to describe all the shapes that may be found, for
we can, at present, neither explain them, nor connect them with any
corresponding difi'erences in the general structure or history of the can-
cers in which they severally occur. But we may observe, as Brucfa and
others have done, on this multiformity as a feature of malignant stm&'
tures : I kuow no innocent tumors, except the cartilaginous, tn which
it is imitated.
In size, the hard cancer-colls range from tb'oo of *" iich to ^i^ of
•Fig
. 84. OinceKcl
Is filliMg inle
rslices among
the buodtea of the fibnM:altuI>r U
■me.
in the skin ofa btensl.
Magnified at
)Oul 200 limes.
tlla.
ilrucltirca are m
inutely discussed by Virchow.in hia Archiv.E
i. p. llOjnndwi
11 be
Bfiain referieil V> in the
leclure on l)it
i gonenil slrnct
ure ofcancen.
JFig.
8S. Celts and free nuclei oT
scirrhous canct
(r: from bream.
MagniQed abcnt
SOD
time).
8CIBBHOU8 0& HARD CANOBR. 497
an inch in diameter. Their medium and most frequent sizes are from
tAo to YiAni • the smaller dimensions are usually found in the cancers of
quickest growth.
In stmeture and general aspect they most nearly resemble, I think, the
■ecreting gland-cells. Examined immediately after removal, and without
addition of water, they appear clear and nearly pellucid ; but changes
qpiickly ensue, which water accelerates, and which bring them to the
diaracters more generally ascribed to cancer-cells. They become nebu-
lofOBy or dimly granular, or dotted, as if containing minute molecules ;
and they look no longer quite colorless, but very lightly grayish or yel-
lowish. The cell-wall is, if it can be seen at all, peculiarly thin and deli-
eaie : but it is often impossible to discern any ; and my belief is, that
the cancer-cells are often only cell-shaped masses of some soft though
tenacious substance, within which are nuclei.
The nuclei in hard cancers are more constant in their appearances
than the cells, and, I think, are even more characteristic. They are
always comparatively large, having an average long diameter of about
»\io of an inch, and varying from this size much less than the cells do
from theirs. They are regular, oval, or nearly round, clear, well de-
fined, scarcely altered by commencing decomposition, or by water, or
tny moderately diluted test substance. A single nucleus is usually con-
tained in each cell ; two nuclei in a cell are frequently found, but not in
all specimens of hard cancer ; more than two are rare : when more than
one are found in a cell, they are generally smaller than those that are
single.
Among the materials of a hard cancer, a certain number of free
nuclei are usually found. It may be difficult to prove that these have
not escaped from cells during the examination : but I think they are na-
turally free nuclei ; for they are often larger than those contained in cells,
and they sometimes deviate from the common shape, after methods
which are more often noticed among the corpuscles of medullary cancers,
and which will be more fully described in the next lecture.
Each nucleus has one, two, or rarely more, nucleoli, which, like itself,
are large in comparison with the ordinary proportion between nucleoli
and cells, and are peculiarly bright and well defined.
These seem to be the normal elements of hard cancer; and such
as we find them in the breast, such are they, but less mingled and
oonfosed with other forms, in the hard cancers of the skin, the bones,
and other organs. Indeed, these characters are so nearly constant and
so peculiar, that an experienced microscopist can very rarely hesitate in
forming upon them a diagnosis of the cancerous nature of any tumor in
which they are observed.
But it would seem as if hard cancer seldom long maintained an undis-
turbed course ; for we seldom find these structures, without finding also
cells mingled with them, in which degeneration or disease has taken place.
82
468 HICBOSOOPIC APPEABANCBB OT THI
Somo of them are withered (fig. 86) ; aome contain minute ofly par&Iet;
some are completely filled with such particles, or are transformed inb)
granule masses (fig. 87) ; and with these, we always find abundant woW
cular and granular matter, in which, as in the d^ris of cells, the nuclu Be
loose. This debris, too, let mo add, is always increased when the eu
is kept for a day or two before examination, and when water acts opoD
it. The loss of clearness by the cancer-cell, of which I have alreadj
spoken (p. 497), is only the first of a series of changes, in the come of
which the material of the cells breaks up into molecolor and amorphov
debris : fragments of it may hang about the nuclei ; but, finally, the cdb
are completely disintegrated, and the nuclei, comparatively tmchaoged,
are set free.
ng.«.»
Among the tissues of the breast itself which are involved by the cancer,
the gland-lobes, I have already said, are quickly removed ; but thor
debris may contribute to the molecular matter which is mingled with the
proper corpuscles of the cancer.
The larger gland-ducts, involved in the cancer, often appear thick-
ened ; and their contents, which are usually a thick, turbid, greasy fluid,
present abundant granule-masses, withered cells, like epithelial cells of
ducts, fragments of membrane, free nuclei shrivelled and deformed, mole-
cular and granular matter : all these being, I suppose, their natural con-
tents, degenerate and disintegrated.
But the more remarkable and characteristic appearances are produced
chiefly or in great part by the smaller gland-ducts, and the fibrons tiasne
inclosed in the cancer. The former chiefly constitute that which haa been
named " the reticulum" of hard cancer, and which has suggested the
name of carcinoma reticulare for the specimens in which it is well Been.^
The most usual appearances of what is now described as "rcticulom" are
two ; and these may exist separately, or may coincide. In one, which
is the most characteristic, and, indeed, the only one to whicli the name
can apply, we sec fine, branching, and variously interlacing and netted
* Fig. 86, Withered hard cancer-cells, wilh d*brii.
t Fig, 87. Hard cancer-celU, ihowiog the progress of fatty degenemtion.
X Under the tiama of Carciuoma reticulare, Mailer inctuiled many cancen that could not
have lieen scirrhous or hard cancers. On this ground, I lliink the nBme had belter mx be
retained ; for, whatever the " reticulum" be formed b;(, it is loo accidental to be considered >
specific ctiaiacter, and is associated with too great diversities of other chaiaeten, to be nied,
BTen arbitrarily, for the deterniioatian of a species. It is not even confined to caoeers: cor-
lesponding appearances may be found in flbro-cellular, cnnilaginous, fibro-nucleated, and
probably several other Inmon (see p. 384, 430, 433).
RETICULUM OF SCIRRHOUS CANCER. 499
Sues, of an opaque-white, buflF or ochre-yellow hue. They appear as
IB if formed of thickly sprinkled dots. They traverse the very substance
if the cancer; and it is important to observe that when the cancer occu-
ves but a small portion of the mammary gland, these netted Hues are
ionnd only in that part of it which corresponds with the gland-substance.
In the other and rarer form of what is also called '^ reticulum," we find
larger dots or small masses of ochre-yellow substance, such as are com-
pared to seeds. These lie more widely scattered in the substance of the
BUicer, and may often be pressed from it, like the comedones, or retained
white secretion from obstructed hair follicles.
I believe that these yellow "seed-like bodies," which are apt, if we
examine them superficially, to be confounded with the degenerate con-
tents of the larger ducts, are always small portions of the cancer dcge-
no^ted and softened, or partially dried. We find in them abundant
gr&nule-cells and granule-masses, some entire, some in fragments ; frag-
ments, also, of granular and nebulous blastema (as it seems), and often of
nucleated membrane ; and these lie in molecular and granular matter dif-
fused in liquid, with minute oil drops, and often with crystals of cholc-
Btearine. But with these products of complete degeneration, we may com-
monly find, also, cancer-cells, of which the great majority are either dege-
nerate, filled with fatty matter, like granule-cells, or disintegrated ; or else
(when the substance is drier) shrivelled and dried up, like the lymph and
pQ8 corpuscles that we may find in chronic inflamed lymphatic glands
(fig. 86, 87).
Similar to these in their component structures are the larger masses of
friable yellow substance, like tuberculous deposits, which are rarely found
in hard cancers, but are very frequent in the medullary cancers.
Now, these appearances of yellow spots, — whether seedlike or in larger
masses, — are not exclusively found in the breast, or. in glandular struc-
tures : they may be seen in any hard cancer, and are yet more frequent
in soft cancers in all organs. But the fine branching and netted lines
that compose the more characteristic reticulum are found, especially, in
cancers of glandular organs : and in those of the breast I have so often
found, among the products of degeneration in them, what appeared to be
portions of withered ducts and epithelium, that I feel nearly sure that
the essential characters of this reticulum, in the scirrhous cancers of the
breast, are to be ascribed to the minuter lactiferous tubes, which, involved
in the cancerous infiltration, are now, with their contents, compressed,
degenerate, and wasting.*
Lastly, respecting the fibro-ccllular and elastic tissues involved in the
cancer, the fate of these, I have said, appears different in different cases.
We sometimes meet with a cancer of the breast, which, having just in-
volved the skin, shows us the interlacing bundles of cutaneous fibres spread
oat or expanded by the insertion of the cancer structures among them (as
* We nmy compare thein with a kind of black reticulam seen in cancers of the lungs or
bronchial glands.
600 CA&CIKOMA FIBBOBUIC
in fig. 84). The skin in such a case appears thickened, and its section is
glossy, gray, and sncculent, like that of hard cancer, but dimly mrked
with whitish fibrous bands. In other and more frequent cases the mtifa
are absent ; and the fibrous and elastic tissues of the skin are not to be
found : we may presume that they have been absorbed as the canoe^
structures increased. I think this removal of the fibrous and elastic tis-
sues is the more frequent event, both in the skin and in the gland; yet
in some of the hard cancers, and in the central hardest parts of others,
the fibrous tissue of the gland — all that which encompasses the gknd-
tubes and becomes, proportionally, so abundant when the secreting stmo*
tures waste — all appears to be even increased and condensed or indu-
rated.
Such cancers as these have been regarded as examples of a spedal
form, named Carcinoma fibrosum, and the fibrous tissue found in them
has been commonly considered as a proper cancerous structure, a re^
of the fibrous development of the cancerous blastema. Now, I shall
have to refer to certain genuine instances of fibrous hard cancer, as occur-
ring especially in the ovaries ; and I would not deny that part of tbe
cancerous material deposited in a breast may be developed into fibroas
tissue ; but I am sure that, in the large majority of cases, the fibroas
tissue which is found in a cancer of the breast is only that which belonged
to the breast itself, and which, involved in the cancer, may now be either
wasted or increased. For the fibrous tissue in hard cancers of the breast
is not like morbid or new tissue, nor like that which is found in really
fibrous cancers, but is like the natural fibrous or fibro-cellular tissue,
either healthy or indurated and condensed. It is also generally mixed
with fibres of elastic tissue, such as are intermingled with the natural
fibro-cellular tissue, but never, I think, occur among the proper consti-
tuents of cancer, and are very rare in even the more highly organized
of the innocent tumors. I may add, in confirmation of this view of the
nature and origin of the fibrous tissue in cancers of the breast, that when
hard cancer occurs in organs which have little or no fibrous tissue, — such
as cancellous bone, the brain, the liver, or the lymphatic glands, — ^it pre-
sents as little or none of the same tissue : however hard it may be, it is
formed almost entirely of corpuscles.'*' The difierence in this respect is
often, indeed, very striking between the hard cancer of the breast and
that of the corresponding axillary glands. Both may be equally hard
and manifestly identical in nature ; yet, while the cancer of the breast
may include abundant fibrous tissue, that in the glands may have scarcely
a trace.f
* See, respecting the bard cancer of the brain, a case well described by Dr. Redfem
(Monthly Joum. December, 1850). I think all that Vircbow, Lebert, and some others baT6
written, is quite consistent with this view, though they seem to hesitate in accepting it
t If it seem strange that in some hard cancers the fibrous tissue of the inTolved organ in-
creases, while in others it is diminished, the strangeness may be made to seem lets by the
more glaring examples of diiference among cancers of bones; — from the eroding teooDdary
80IBBH0U8 OB HARD GANGER OF THE BREAST. 601
I have dwelt the more on this point because the current method of
describing all cancers as composed of a peculiar ^' stroma," the meshes of
which are filled by a peculiar ^^cancer-juice/* appears to me very decep-
tire, and often incorrect The expressions, as they are commonly used,
imply that the fibrous tissue or stroma, and the cells and other materials
which form the juice, are alike proper and essential to the cancer. But
I believe that in the large majority of cancers of the breast, the only
^stroma," the only substance that would remain, after removing all that
is cancerous, would be the structures of the breast itself. And so, in
other cancers, my belief is, that if we except the rare examples of the
really fibrous and osteoid cancers, to which I shall hereafter refer, there
are few in which more than a very small quantity of fibrous tissue is
formed.
In the foregoing description I have had in view, almost exclusively, the
forms of hard cancer which are most frequent in the breast ; instances
of the ordinary or typical characters of the disease. But, as I said at
the outset, the deviations from these medium forms are neither few nor
inconsiderable, even though we do not count among them any of the
varieties of appearance which are due to degeneration or to disease of
the cancerous structure, or to varying conditions in the parts about the
mammary gland.
And, first, varieties appear which may be referred to diiferent degrees
of activity or intensity of the disease. The examples which I have
hitherto chiefly described might hold a middle place in a series, at the
opposite ends of which would be those of what have been sometimes
odled the "acute" and the "chronic" cancers.*
The well-marked examples of the former kind are distinguished, not
only by rapid progress, but by structure. They are scarcely to bo called
hard — ^they are, at the most, firm, tense, and elastic ; and they may even,
though not morbidly softened, present a deceptive feeling of fluctuation.
Their cut surfaces do not become concave ; they are succulent, and yield
abundant fluid upon pressure ; they are often sufiused with vascularity,
especially about their borders. The quantity of cancer-structure in them
is very large, in proportion to the quantity of gland in which it has its
seat. Hence the section of an acute cancer appears more homogeneous,
and its growth produces a manifest enlargement or swelling, the morbid
material expanding the tissues around and involved within it. The sur-
rounding tissues, also, are less closely connected with the cancer than
they usually are, and it may appear like a distinct isolated tumor, rather
than an infiltration.
hard cancers, in which the osseous tissue wholly disappears, to the medullary cancers, in
which the osseous tissue increases commensurately with the cancer and grows out into it as
a spongy skeleton or framework.
* Most of the acute forms are such as some call f2a«<tc cancers: most of the chronic would
be claseed BsJUmma cancers by those who adopt that term. " Hypertrophic" and ** atrophic"
haye alio bean applied to them as terms of contrast
502 SCIBBHOUS CANOEB OF THE NIPPLE AND AREOLA.
In all these conditions the acute scirrhous cancers aprozimate to the
characters of medullary cancers ; and perhaps the expression is not imJTist,
that they are examples of an intermediate form of the disease. And the
approximation is shown in some other characters, especially in their moie
rapid growth ; in their usually affecting those whose mean age is below
that of the subjects of the harder and more chronic cancers ; and in the
signs of larger supply of blood.
In the chronic hard cancers the opposites of all these cliaracten are
found. The cancerous mass is comparatively small ; and, as time passes,
it often seems to shrink and contract, rather than increase. It is intensely
hard, knotted, and dry ; the adjacent tissues appear tight-drawn to it,
and firmly adherent ; and on its cut surface, which usually appears deeply
concave, it may show more of the increased and indurated fibrous tissue
of the breast than of the proper cancer substance. All the history of
the chronic cancers accords with these signs of inactivity : they occur
generally in those that are beyond the mean age ; they are attended witli
no increase of vascularity ; and if the skin became involved in one, it is
only ruddy or palely livid at the very seat of adhesion. The tissues of
the breast itself usually appear to suffer a corresponding atrophy ; the
gland commonly shrivels, and the skin becomes lax and wrinkled, or ebe
is fiUed-out with superabundant fat accumulating round the shrinking
gland.
Either of these forms of cancer may affect, in some cases, the whole
gland ; in others, only a portion of it. The characters of both are most
marked when they occupy the whole gland, for now the enlargement attend-
ing the acute cancer, and the shrinking that accompanies the chronic, are
most manifest.
In general, the respective characters of the acute and the chronic can-
cer are consistent throughout all their course : yet cases are not rare in
which a scirrhous cancer has shown all signs of rapid progress at the
beginning of its career, but, after a time, has inexplicably retarded its
course, and passed into a chronic state. Nor, on the other hand, are
those rare in which patients are seen dying quickly, because a cancer,
which has been slowly and almost imperceptibly progressive for several
years, at length assumes the rapidity and destructiveness of an acute
inflammation.
A second series of hard cancers, deviating from the usual forms, con-
sists of cases in which the nipple and the skin or other tissues of the
mammary gland are peculiarly affected.
Commonly the hard cancer extends from the mammary gland to the
nipple and areola, involving these as it may any other adjacent part
When seated at or near the centre of the gland, it commonly draws down
the nipple, which descends as it were into a round pit sunk below the
general level of the breast. As it extends, also, the cancer-structuree
SCIBRH0U8 OB HABD CANCER IN LTMPHATIC GLANDS. 508
deposited in the nipple make it hard, or very firm and elastic, inflexible,
ind comparatiYely immovable. Bnt the changes which thus usually
oeenr later, or in a less degree, than those in the gland, may commence
or predominate in the nipple or the areola. The former may be found
quite hard and rigid ; or, in the place of the latter, there may be a thin
layer of hard cancerous substance, with a superficial ulcer, like an irre-
gular excoriation, while the structures of the gland itself are yet healthy.
In other cases, we find the skin over and about the mammary gland
exceedingly affected. In a wide and constantly, though slowly, widening
srea, the integuments become hard, thick, brawny, and almost inflexible.
The surface of the skin is generally florid or dusky with congestion of
Uood; and the orifices of its follicles appear enlarged, as if one saw it
magnified, — ^it looks like coarse leather. The portion thus affected has
an irregular outline, beyond which cord-liko offshoots or isolated cancer-
ous tubercles are sometimes seen, like those which are common as sccon-
dmiy formations. The mammary gland itself, in such cases, may be the
seat of any ordinary form of hard cancer ; but I think that at last it
generally suffers atrophy, becoming, whether cancerous or not, more and
more thin and dry, while the skin contracts, and is drawn tightly on the
kmy walls of the chest, and then becomes firmly fixed to them.
I might add to the account of these deviations from the ordinary forms
of cancer of the breast, notices of some others ; but these may suffice,
and if it be remembered that each of these, as well as of the more com-
mon forms, is liable to change by the various degenerations and diseases
of the cancer, enough will have been said to illustrate the exceeding
multiformity in which the disease presents itself in the breast. Some-
thing, however, must be added respecting the characters of scirrhous
cancers in other parts of the body ; and from these I will select chiefly
those parts in which it has the greatest surgical interest, or has received
the least attention from morbid anatomists.
Li the Lymphatic Glands, the scirrhous or hard cancer appears very
frequently as a secondary disease ; indeed there are few cases in which
cancerous patients reach their average of life without affection of the
glands connected with the organ primarily diseased. But, as a primary
disease, scirrhous cancer of the lymphatic glands is very rare : the can-
cer which most commonly appears first in them is the medullary ; espe-
cially, I think, that of the firmer kind.* A specimen is in the Museum
of St. Bartholomew'Sjt which shows well-marked scirrhous cancer in an
* The Index will, I hope, in some meii^ure correct the disadvantnge, which is here evi-
dent, of separating the accounts of tlie different forms of cancer in the same organ. Tlie
dindvaniBge is, I think, more than compensated by the avoidance of confusion in the de-
■eriptions of the different forms; and in the Index the reader will find, under the title of
each chief organ or tissue (so far as tliey are here described), the references to all the forms
of cancer occurring in it. t Series xxi. 2.
504 SCIBRHOUS OB HARD CAKCB& IN LYMPHATIC eiiAIDB.
inguinal gland. The gland is increased to an inch and a half in length,
and, while retaining its natural shape, nearly the whole of its pnyper
texture appears replaced by structures exactly resembling, in hardiken
and all other properties, the ordinary scirrhous cancer of the breast It
was removed by Mr. Lawrence from a lady, who remained well about three
years after the operation, and in whom the disease then recurred in ano-
ther inguinal gland, which was also removed, and presented the umt
characters. They were equally marked in the progress through destroo-
tive ulceration which ensued in a primary scirrhous cancer of the axillary
glands, also observed by Mr. Lawrence. I believe I saw a third instance
in some inguinal glands, which formed an exceedingly hard swelhng in
and below the groin ; but I had no opportunity for minute examination
of them. There was no probability, in any of these casea, that any
other part was the seat of cancer before, or at the same time with, the
lymphatic glands.
Gases sometimes occur in which the disease in the glands may be so
nearly coincident with that in the organ to which they are related, that
we may believe the gland-cancer to be primary, though not alone. And
sometimes the disease in the glands greatly preponderates over that in
the organ, even though its primary seat was in the latter. A woman,
60 years old, was lately in St. Bartholomew's Hospital, in whose right
breast there was a hard lump, less than a pea in size, which felt exactly
like a hard cancerous tumor imbedded in the gland. This had existed
unchanging for twenty years ; and in the right axilla a cluster of lympha-
tic glands had been rapidly enlarging for twelve months, and now formed
a great mass so uniformly hard, heavy, and nodular, as I have never seen
formed by any glands but those affected with scirrhous cancer. The
case, is, however, imperfect, for the patient would submit to no operation,
and there may remain some doubt as to the nature of the smsJl tumor
in the breast.
All these, however, are comparatively rare events. The ordinary
course is, that after the scirrhous cancer has existed for a time (the
length of which seems at present quite uncertain), in the breast or any
other organ, the lymphatic glands in and near the route from that organ
towards the thoracic duct become the seats of similar disease. I shall
speak elsewhere of the probable method of this extension of the cancer
to the glands. Its effects are shown in a process which, in all essential
characters, imitates that preceding it in the organ primarily diseased.
Usually the cancerous material is deposited, and its structures are formed,
in the first instance, in separate portions of one or more glands. The
separate formations appear as masses of very firm and hard whitish or
grayish substance, of rounded shapes, imbedded in the glands, and con-
trasting strongly, as well in texture as in colour, with their healthy re-
maining portions. But, as the separate portions in each gland enlarge,
they gradually coalesce till the whole natural structure of the gland is
80IBBH0U8 OB HABD CANOBB OF THB SKIN. 605
Oferwhelined and replaced by the cancer. Similarly, the same changes
ensiling at once in many glands, they form a large and still increasing
ekister, and at length coalesce in one cancerous mass, in which their seve-
ral outlines can hardly be discerned.
The minute texture of the hard cancer of lymphatic glands differs, I
believe, in nothing that Is important from that already described in the
cancer of the breast. Only, in microscopic examinations we find the proper
Btmcture of the lymphatics, in the place of those of the mammary gland,
mingled with the ceUs and other constituents of the cancer. Neither
IB there any essential difference in the mode of deposit of the cancerous
material; it is, in both alike, an infiltration, though circumscribed.
Occaeionally, it is said (but I have never seen it), the secondary cancer
of the lymphatic glands is soft and medullary, while that of the organ
primarily diseased is scirrhous. Very often, before becoming cancerous,
the lymphatic glands enlarge without hardening, — through '^ simple irri-
tation," as the expression is. From this condition they may subside
after the removal of the primary cancer, or when corresponding '^ irrita-
tion" in it is relieved. But the condition, whatever it may be, is proba-
bly not one of mere slight inflammation ; for glands which may have thus
snhsided, or which have not been visibly affected, may become the sole
or primary seats of recurrent cancer, even two or more years after the
removal of the primary disease. There seems to be a peculiar state of
liability to cancer, long retained in lymphatic glands, sometimes testified
by enlargement, but often not discernible except in its results.
Scirrhous Cancer of the Skin is another of the affections commonly
occurring secondarily, yet sometimes appearing as a primary disease. Its
occurrence, when the disease extends continuously from the mammary
gland, is already described. In a similar manner it may be found extend-
ing from lymphatic glands, or any other subcutaneous organ ; and I have
described (p. 503) how it sometimes precedes and surpasses in extent the
scirrhous cancer of the breast. But its most frequent appearance, in
connexion with cancer of the breast, and that which is imitated when it
occurs as a primary disease in other parts of the skin, is in tubercles or
rounded hard masses.
Such tubercles are generally grouped irregularly, but in constantly
widening areas, about the primary disease in the breast ; in other parts,
and as primary cancers, they may be single or numerous. They are al-
most incompressibly hard, tough, circumscribed masses or knots ; they
are usually of oval, flat, or biconvex form, or, when large, are tuberous
or lobed; they are imbedded, as infiltrations of cancer-structures, in the
exterior compact layer of the cutis. They arc generally equally prominent
above, and sunken beneath, the level of the surface of the skin ; and this
condition is commonly acquired as well by those which commence like
little prominent papulae, as by those which at first appear like knots
506 SCIBBHOUS 0& HARD CANCER OF THB XUSCLBS.
just subcutaneous. The skin covering them is thin, tense, and shining;
it is usually of a deep ruddy pink color, tending to purple or browiudi-
red, or it may seem tinged with brown, like a pigment-mark. This chinge
of color extends a little beyond the border of the cancerous mass, and
then quickly fades into the natural hue of the skin. Such cancers ire
movable with, but not in, the surrounding skin, and even with it th«
mobility is very limited when they are large and deep. They may be
found of various sizes ; in circumscribed masses, ranging from such a an
as can just be detected by the touch, to a diameter of two inches; or,
when diffused in the skin, occupying it in an expansion of hardly limited
extent.
The minute structures, equally with the general characters, of the
scirrhous cancers of the skin, are, in everything, conformed with those
already described; and the characters of cancer-cells, and their mode
of disorderly insertion in the interstices of the natural tissues, are in no
parts more distinct. "*"
In general, I think, the scirrhous cancers of the sldn have a chronic
course, not painful, nor soon ulcerating ; but, as primary diseases, they
are too infrequent for a general history of them to be written at present
I have seen only four examples of them independent of previous cancer
in other parts. In one of these the seat of disease was nearly the whole
skin of the front of the left side of the chest of a woman 73 years old;
in another, it was in the skin of an old woman's leg ; in another, an
elderly man's scalp had two large, hard, cancerous masses in it; in a
fourth the disease was in the scrotum of a man 53 years old ; but I be-
lieve the elementary structures of scirrhous cancer were mingled with
others resembling those of the more frequent epithelial soc^t-cancer of
the same part.t
In the Muscles, scirrhous cancer is commonly associated with its
most frequent form in the skin : that, namely, in which it occurs in
groups of tubercles about the primary disease of the breast. We may,
indeed, draw a close parallel between the secondary cancers in the skin
and muscles respectively : for in both parts alike we find, in some cases,
* In the foregoing account I have not had in view that which is commonly caUed the
" cancerous tubercle of the face," and which so often occurs as the precedent of the de-
structive process constituting the so-called " cancerous" or " cancroid ulcer" of the fiice in old
persons. I have not been able to examine minutely one of these tubercles before ulcentr
tion, but all I have seen of the materials forming the base and margins of the ulcers which
follow them, and all the characters of their progress, make me believe that no cancerous
structure, whether scirrhous, epithelial, or any other, exists in tliem. I shall revert to thti
subject in the lecture on Epithelial Cancer.
t This specimen is in the Museum of St. Bartholomew's. Cases of cancer of the skin
are related by Lebert, Walshe, and others, in their appropriate chapters ; but it is not dew
that any of them were primary scirrhous cancers. Tliose which were not epithelial canceit
appear to have been either medullary, of the firmer sort, or (in Lebert's cases) melanotic.
All these forms of cancer are more frequent in the skin, as primary diseases, than that
which I have described: they will all be considered in the following lectures.
SCIRBHOUS OB HABD CANCEBS IN BONES. 507
discrete cuicerouB tubercleB, in others extensively difinsed cancerous
deposits ; and in the muscles, as in the skin, the latter form occurs
especially when the disease extends continuously ; the former when it is
multipIicKl contiguously to its primary seat.
I have never seen a primary scirrhous cancer in a muscle ; and only
once seen such a cancer forming a distinct isolated tumor in an inter-
muscular space. It may be doubted, indeed, whether this tumor were
the primary disease ; yet, because of the exceeding rarity of scirrhous
cancers in any other form than that of infiltrations of the textures of
parts, it deserves mention. It was taken, after death, from a man 54
years old, in whom it had been observed for a month, and who died,
exceedingly emaciated and exhausted, with similar disease in his axillary
and bronchial lymphatic glands, his lungs, muscles, occipital bone, and
other parts. This tumor was about four inches in length, oval, surrounded
by a distinct fibro-cellular capsule, and seated between the brachialis
anticus and biceps muscles, outspreading both of them. It had the same
hardness, weight, and density, and the same microscopic cell-structures,
as the ordinary hard cancers of the breast ; it was milk-white, slightly
Bufiiised with pink and gray, and distantly spotted and streaked with
ochre-tints. The other cancerous masses had for the most part the same
characters ; but some, which by their size and positions might certainly
be considered as of latest production, were soft, and like the most fre-
quent medullary cancers.
In the Bones, as in the muscles, the scirrhous cancer seldom, if ever,
occurs except as a secondary disease : the primary cancers of bones
are, I think, always either medullary, osteoid, or colloid. The structures
of the scirrhous cancer may be infiltrated or difiused among those of the
bone, or they may form distinct masses ; but in neither case do they so
increase as to form considerable tumors. In some of the cases of infil-
tration, the cancerous substance is diffused through the cancellous tissue
of the bone, while its walls are comparatively little changed : in others
all the bony structures are expanded into an irregular framework of
plates and bands, the interstices of which are filled with cancerous sub-
stance, hard, elastic, gray, and shining.* On the other hand, when
separable cancerous masses are formed, they are usually round or oval,
or adapted to the shape of the ipner walls of the bone, within which they
are, at least for a time, confined. They generally appear as if, while
they were growing, the original bony textures around them had gra-
dually wasted or been absorbed, making way for their further growth.f
* Nos. 822-3 in the College Museum are examples of the first form ; and No. C (Appen-
dix) in that of St Bartholomew's may exemplify the second. Tlie latter specimen was
taken from a case in which a cancerous femur was broken eight months before death, and
the new bone, with which it was repaired, was infiltrated with cancer as well as the
original textures.
"f See, respecting the occasional " preparatory rarefaction" of bones, previous to cancerous
deposits in them the excellent observations of Walshe (p. 655) and Virchow (Archiv^ 1. 126.^
608 SOIBBHOITB OB HARD OAHOBB
And thus the growth of the hard cancer, with absorption (whether^
vions or consequent) of the bone around it, may continne till not inly
the medullary tissue, but the whole thicknest d
^' "*■* the wall, is removed, and the cancer may project
through and espand beyond it, or may alone fill
the periosteum, retaining, with very little change,
the original shape and sise of the bone.t
In both these sets of cases the cancer-cells ixt
alike, and they form, without fibrous tissue, t
hard, or very firm, elastic, grayish substance,
shining, and sometimes translucent, sometime^
with an obscure fibrous appearance. The like-
ness to the common hard cancer of the breast ii
complete, in both general and micr08c<^ic charafr
ters ; and not less complete the contrast with the
usual forms of the medullary cancer, which, as I
have said, is the more frequent primary diseui
of the bones. Intermediate specimeos may, m-
deed, be found ; yet, on the whole, the contrast
between medullary and scirrhous cancers is as well
marked in the bones as in any other part.^
The bones thus cancerous become liable te bt
broken with very slight forces ; and to these condi-
tions a certain number of the so-called spontaneosi
fractures in cancerous patients may be assigned
But some are due to the wasting and degenert-
tive atrophy which the bones undergo during tba
progress of cancer, and which seems to proceed
to an extreme more often than it does in any other
equally emaciating and cachectic disease.
The hard cancer of the Intestinal Canal, exemplified most fre-
quently in the upper part of the rectum, in the sigmoid Bexure of the
colon, and, sometimes, in a very striking form, in the ileo-ctecal valv^
appears, usually, as an infiltration of hard cancer-structures in the snV
mucous tissue. Here it is usually of annular form, and occupies the whok
circumference of the intestine, in a length of from half an inch to an
inch. The cancer may, at tho same time, or in other instances, occur
• Fig. 88, Section of a humerus wiih liarci cancer, as described abovs. Miu. orStBuilx)-
t As in Nos, 817-e-9, in ihc Museum of ihe College, and in seveml specimeiu lateljf added
to iliBi at Si. Banholomew's.
} Meilultary cancer may appear hs a gecondary disease in Ihe bones, at welt aa in otbar
pans, after primary scirrhous cancer in the breasl. The cases I have examined would
make me think Ibai t)ie scirrlious cancer is, in these evenls, Ihe more frequent: bnt M.
Leben (Traite des Maladies Cancereuses, p. 714) describes none but wft cancer* ■• ooeiu^
ring in the bones, whalhet primarily oi secondarily.
OF TBI LABQE IKTBSTIKES. 609
otemallj to the nrascnlu- coat, and in this case is oBnally not annulw
but in Bepanta tnberclea, which, until ulceration ensues, project with
flattened and sometimeB centrally depressed, round or ova] surfaces,
into the cavity of the intestine. Very rarely (it is said) it may affect
the whole drcomference of a large extent of the rectom, and may in the
same extent involve many adjacent parts.
It sometimes haf^ens that the hard cancer of the submucous tissue is
BBBoriated with growths of softer medullary cancer into the cavity of the
intestine, or with formations of colloid cancer. The mingling of these
fbima is certunly more frequent in the
digestive canal than in any other part. '''*' ^**
But that which is most remarkable in
the hard cancers of the rectum (as an
example of those of other portions of
the canal), is derived from the tendency
which the cancer has here, as in other
parts, to contract and condense, and
adhere to the parts around it. 1o this
it is due, that, when an annular cancer
of the rectum exists in the submucous
tissue ; even the exterior of the bowel
appears constricted ; instead of swell-
ing, the bowel is, even externally,
■mailer at the cancer than either above
or below it: and the stricture, or narrow-
ing of the canal, which would be trivial
if it depended only on the cancerous
thickening of the coats, is made extreme by the contraction o^ the coats
around and with the cancer. The same conditions which, in hard cancer
of the breast, produce retraction of the nipple and puckering of the skin
; over the morbid growth, here produce contraction of the muscular and
I peritoneal tissues around the growth, and a concentric indrawing of the
growth itself.
With similar likeness to the hard cancers of the breast, those in the
, intestine (in the rectum, for example) give rise to close adhesion of the
I tissues round them to other adjacent parts. Thus the cancerous part
of thd rectum may be fixed to the promontory or front surface of the
sacrum quite immovably ; or the colon may become united to the urinary
Uadder, or to some other portion of the intestinal canal.
Many other important facts in the history of this affection arc connected
with the dilatation and hypertrophy of the intestine above the stricture;
the final paralysis of the dilated part, and the phenomena of ileus chiefly
due thereto, with displacement of the diseased part by the weight of
510 FIBROUS HARD OAKCSRS IK THH OYABIBS, XTG.
faeces accumulated above it ; the occasional yariations of the degree ot
stricture, according to the afflux of blood swelling the diseased part, or
its ulceration or sloughing decreasing it, and so, for a time, widemngthe
canal ; but these I need only enumerate, while I can refer to Rokitanskj*
for ample accounts of them all.
The large intestine is, probably, next to the mammary gland and the
stomach, the organ in which the well-marked scirrhous cancer is most
frequently found as a primary disease. It very rarely, indeed, ocenrB
secondarily, except when extending to the intestine continuously from
some adjacent part ; and in this case, as it usually affects, at first, only
part of the circumference of the intestine, it may become much more
extensive without producing stricture ; for the unaffected part of the wall
may dilate so as to compensate, for a time, for the contraction of the
diseased part. Moreover, when it is a primary disease, the cancer of the
intestine is one of the forms in which the disease may exist longest without
multiplication, although often, even in its early stages, it is associated
with exceeding, and seemingly disproportionate, cachexia.
I have spoken of the occurrence of fibrous tissue in the scirrhous can-
cers of the breast, and have said (pp. 499, 500) that this appears to be no
proper element of the cancer, but the natural fibro-cellular and elastic
tissues of the part involved in the cancer, and often increased and con-
densed. If this be always so, and if, as I have also said, little or no
fibrous tissue be found in cancers affecting organs which naturally con-
tain none, it will follow that the name Carcinoma fibrosum is not weD
applied to any examples of hard cancers described in the foregoing pages.
Yet there are cancers which contain not only abundant but peculiar
fibrous tissue ; and these may well be called " fibrous cancers," and may
be considered as a distinct form or species, unless it should appear that
they are always associated, as secondary diseases, with scirrhous cancers
of the more ordinary structure : so that we may suppose that the sane
blastema is, in one organ, developed into fibrous tissue ; in others, at the
same time, into cancer-cells.
The most remarkable examples of hard cancers with fibrous structures
that I have yet seen, have been in the ovaries of certain patients with
common hard cancer of the breast or stomach, f In these cases, the
place of the ovary on either or on both sides is occupied by a nodulated
mass of uniformly hard, heavy, white, and fibrous tissue. The mass ap-
pears to be, generally, of oval form, and may be three or more inches in
diameter: its toughness exceeds that of even the firmest fibrous tumors;
and its component fibres, though too slender to be measured, arc pecn-
liarly hard, compact, closely and irregularly woven : they are not undu-
lating, but, when they can be separated singly or in bundles, they appear
* Pathologische Anatomic, III. 270 and 2S2.
t Museum of tlie College, No. 240, 2036} and of St. Bartholomew's, xxn. 17, and, pro-
bably, xxxil. 14.
I
B0IBBH0U8 OB HABB OAKOEB. 611
brk-edged, short, and irregularly netted. With these I have found only
aw and imperfect cancer-cells ; with more numerous nuclei, elongated
nd slender. They are not mingled with elastic or other ^^ yellow ele-
lent" fibres.
It may be not unfairly supposed that the same blastema, which in
tlier organs may be developed into cancer-cells, may become fibrous in
rgans of so singular capacity for morbid as well as natural develop-
lent^ as are the ovaries. But fibrous cancers are not found in the ova-
ies alone. Peculiar stifi'-fibred tissue is sometimes contained, together
ith less abundant cancer-cells, in the harder cancers connected with
flriosteum. So I have seen it in the pelvis, and in the unossified parts
f osteoid cancers, where neither its relations nor its minute texture were
uch as to suggest that it was morbidly increased periosteum. However,
lie occasions that I have had of examining truly fibrous cancers have
eon too few, to justify any conclusion respecting the propriety of sepa-
ating them, as a distinct form, from the scirrhous cancers. And I can-
ot complete my own imperfect observations with the records of other
•athologists ; for I think that none have endeavored sufficiently to dis-
riminate between the two kinds of fibrous tissue that may be found in
ancers ; namely, that which is developed from cancerous blastema, and
hat which is derived from the original fibrous tissue of the afiected organ,
rheiher in its natural state, or increased, condensed, indurated, or other-
rise morbidly changed. Yet the distinction is an essential one : for the
(xrmer is truly cancer-structure, the latter is only the structure in the
aterstices of which the cancer has its seat. A similar distinction will
lave to be made, in a future lecture, between the osseous tissue that
;rows so as to form the framework, or interior skeleton, of certain medul-
ury cancers of bone, and that which is the chief constituent of osteoid
ancers : the one is a morbid growth of a bono affected with cancer ; the
•ther is the proper cancer-structure ossified.
LECTURE XXX.
SCIRRHOUS OR HARD CANCER.
PART n.— PATHOLOGY.
Thb former part of this lecture being devoted to .an account of the
tnictures of the chief examples of hard or scirrhous cancers, I propose,
a this second part, to consider their history, their mode of life, their
»athology as contrasted with their anatomy. And here, even more nearly
ban in Uie former part, I will limit myself to the histories of those of
he breast ; for, concerning the primary hard cancers of other parts, we
lave too few data for any general history.
612 IKFLUEKOH OF AeE AND 81Z.
First, concerning the conditions favorable to the origin of these Bd^
rhous cancers : —
(a.) They exist, in great preponderance, in women. Probably, U
every 100 cases of scirrhous cancer of the breast, 98 occur in wom^;
and, I believe, it is chiefly this that makes cancer, on the whole, more
frequent in women than in men, for in every other organ common to both
sexes, the greatest frequency is, I think, found in men.
(5.) The age of most frequent occurrence of scirrhous cancer of the
breast, is between 45 and 50 years. Nearly all records I think agree in
this. The disease has been seen before puberty ; but it is extremely
rare at any age under 25 ; after this age it increases to between 45 and
50 ; and then decrease£uin frequency, but at no later age becomes so in-
frequent as it is before 20.
The following table, drawn from the records of 158 cases, of irhA
the diagnosis cannot be reasonably questioned, will illustrate the fore-
going statement : — *
2 cases were first observed between 20 and 25 years of ag6.t
4
9
26
33
40
17
11
9
u u u
u u u
u u u
u u u
u u a
tt u tt
u u u
tt u u
6 " " " 70 " 80 "
1 " " above
25
u
30
30
tt
35
35
tt
40
40
u
45
45
tt
50
50
tt
55
55
C(
60
60
M
70
70
tt
80
80
158
These numbers may represent the absolute frequencies of the occurrence
of hard cancer of the breast at different ages. But it is more important
to know the relative frequencies in proportion to the number of women
living at each of the successive periods of life. To ascertain this I hare
added to the cases in the preceding table those tabulated, in a nearly
similar manner, by M. Birkett| and M. Lebert;§ making a total of
* This and most of the following tables are drawn from a general table of 365 cases of
cancers of all kinds. Of the whole number nearly half were observed by myself. Of
the remainder, I have derived about 50 from the records of the Cancer- wards in the Kid-
dlesex Hospital, for access to which I am much indebted to the surgeons of the hospital : more
than 60 were very kindly communicated to me by Mr. Humphry ; others I owe to Mr.
Lowe and Dr. Paget : nearly all the rest were collected from the works of Wardrop, Lug*
staff, Baring, Bruch, Bennett, and Sedillot
t The ages assigned in this table are those at which, in each case, the disease was first
observed by the patient / and no case is included which was recorded only, or chiefly
because it was an example of the disease occurring at an unusual period of life.
X On Diseases of the Breast, p. 218.
§ Des Maladies Cancereuses, p. 354. The particulars of both these tables accord veiy
nearly with those given above ; but the numbers of cases below 20 and abore 80, in Mr.
Birkett*s table, are very large ; probably because he has included cases that were recorded
on account of their rarity in respect of the patients' ages.
IHVLUSKOB or AGB. 618
S54 cases originatmg between the ages of 20 and 80 years. Then, com-
paring the number of cases in each decennial period of life, with the
mmber of women alive in the same period in England and Wales
(aecording to the Popnlation-Retums for 1841), it appears that the com-
parative frequencies, relatively to the whole number of women, may be
•tited in the following ntmibers : —
RalaftiTt freqotMgr of th*
Afct. origin of hftrd euioir.
30 to 30 6
30 « 40 40
40 « 60 100
50 " 60 76
60 " 70 38
70 " 80 32
In other words, the proportions between these numbers may represent
tie degrees in which the conditions of women's lives, at the successive
decennial periods, are favorable to the first growth of hard cancer in the
breast.
One is naturally led to suppose that the great liability to cancer of the
breast between 40 and 50 years of age, and especially the maximum
between 45 and 50, are connected with some of the natural events that
are then occurring in the nearly related reproductive organs ; such as
the cessation of the menstrual discharge, and of the maturation of ova ;
or else with the wasting and degeneracy of the mammary glands. And
yet it is difficult to prove such a connexion with any single event of the
period.
The event which is generally regarded as most important is the cessa-
tion of the menstrual discharge. But I find that among 52 women with
scirrhous cancer of the breast, in whose cases this point is noted, 27 were
stOl menstruating for at least a year after their discovery of the cancer ;
and 16 had ceased to menstruate for a year or more previous to it ; so
that less than ^ of the whole number afforded examples of the cessation
of the catamenia and the discovery of the cancer occurring within the
same year.
The following table shows the. ages at which menstruation ceased in 400
women,'*' and the ages at which hard cancer of the breast was first
detected by an equal number : —
of FIrtt oXmufwXkm
memlnutioii. oftbeeanotr.
Below 35, . . 0 .... 36
35 to 40, . .51 62
40 to 45, . . 140 .... 78
45 to 50, . . .159 101
Above 50, 41 .... 123
400 400
* From Dr. Guy*! tablet, in the Medical Times, 1845. The numbers in the third column
are obtained by doubling those in a table of 200 cases, collected from those of M. Lebertand
Mr. Birkett, as well as fiom mj own.
83
614 CONDITIONS OF GENERAL HEALTH.
All these calculations are sufficient to prove the great influence whicli
the events of life, at and about the time of the cessation of the menstnul j
process, exercise in the production of cancer ; but they do not prove that
the defect of that process has more influence than others of the coineideut
events. I think we may most safely hold that the aptness of this time u
of life for the development of hard cancer is chiefly due to the general :|
failure of the process of maintenance by nutrition, which usually has at
this time its beginning, and of wliich the most obvious natural signs are
in the diminution of the powers of the reproductive organs. It is in
favor of this view, rather than of any especial influence of the reprod1l^
tive organs, or of change in the mammary gland, that, so far as we can
estimate, with so small a number of cases as are yet on record, the ages
of increasing frequency of hard cancer in the male breast,* and of
primary hard cancer in other organs, coincide with the results of the &r
more numerous cases in the female breast. This would hardly be so if
it were the condition of the female breast itself, or of any nearly related
organ, that alone or chiefly determined the greater frequency of the can-
cer at particular periods of life.
(c) To these conditions of sex and age, as favoring the production of
scirrhous cancer, we may add an hereditary disposition, and the effects
produced by injury or previous disease. The influence of these ^nditioos
is not generally, but is often very clearly manifested. In 88 patienti
with hard cancer (including four men and four cases of hard cancer of other
organs than the breast), 16 were aware of cancer having occurred in other
members of their families. In 40 tabulated by M. Lebert only 6 could be
deemed hereditary.f Probably, therefore, not more than 1 in 6 patients
with hard cancer can be reckoned as having hereditary tendency thereto.
And it does not appear that such a tendency, even where it exists, leads
to an unusually early manifestation of the disease ; for the mean age of
the hereditary cases which I have collected is very nearly the same as
that of the others ; namely, about 48 J years. The occurrence of hard
cancer in many members of a family cannot, then, be deemed frequent ;
yet, when it is observed, it is often too striking to leave any doubt about
the reality of an hereditary tendency to the disease.
(d) So, with regard to the effects of injury and previous disease, I find
that, among 91 patients, only 16, i. e. less than one-sixth, ascribed the
hard cancer to injury or any such local cause. The proportion is so
small (it is less even than that of the patients with other tumors, who
* The four men in whom I have seen hard cancer of the breast were respectirely 40, 44,
48, and 52 years old at tlie discovery of the disease.
t The difference in the proportions of M. Lebert's cases and in mine is probably due to my
having reckoned as hereditary, three cases in which members of the family Iiad had cancers
of the lip. These would be excluded as only *• cancroid" by M. Lebert ; and so exclnde<l
and added to the non-hereditary cases, they make the proportions very nearly equal in both
our estimates.
SCIBBHOUS OAKOBR. 515
ascribe them to the same canse*), that vra might be disposed to deny the
inflaenoe of injury altogether, if its consequences were not, in a few cases,
so manifest and speedy.
{e) I pass by some other conditions supposed to be favorable to the
occurrence of scirrhous cancers ; such as mental distress, particular occu-
pations and temperaments. Concerning all these, the numerical evidence
at present gained is insufficient to justify any conclusions. But, respect-
ing one point much discussed, namely, the general health of women at
the time when hard cancer is first found in them, I would observe that a
remarkable majority present the appearance of good health. I find that
HI 91 cases in which I have notes on this point no less than 66 patients
presented the general characters of robust, or, at least, good health ; 9
were of uncertain or moderately good health ; and only 16 were sickly
or feeble. It does not follow that all these were manifestly ill when the
cancer began to form ; but, granting that it may have been so, it would
still appear that scarcely more than one-fourth of the subjects of hard
cancer are other than apparently healthy persons. From all this it is
evident, that, except in relation to the comparative liabilities of different
ages, we have little knowledge of the events that are, in any sense, the
predisposing causes of hard cancer. Indeed, so insignificant in their
whole mm are those that are already ascertained, that, in a large majority
of cases, the patient finds the cancer by some accident. She chances to
tOQch her breast attentively, or she feels some pain in it, or her friends
notice that it ia smaller or larger than it used to be ; and now, already,
there is a cancer of, it may be, large size, of whose origin no account
whatever can be rendered.
The fact last mentioned may explain why we so rarely have an oppor-
tonity of seeing what a hard cancer is like at its very beginning. I have
examined only three that were less than half an inch in diameter. All
these were removed within two months of their being first observed, and
all had the perfect cancerous structure, such as I have described as the
type. I believe they illustrated what is generally true — namely, that
the cancerous structure has, from the first, its peculiar hardness. The
formation of it appears to be attended with gradually increasing indura-
tion, only in the cases in which, from the beginning, it afferts the whole
gland, and those in which it acquires even more than usual hardness, by
the gradual predominance of the increased and indurated fibrous tissue.
From the extreme of smallness the cancer grows ; but at various rates,
in different cases, and even in the same case, at different times. I be-
lieve no average rate of increase can be assigned. Cases sometimes occur,
especially in lean, withered women, whose mammary glands share in the
generally pervading atrophy, in which two, three, or more years pass
* See p. 329. Of 79 tumors not cancerous 15 were ascribed to injury or previous disease,
i e. 1 in nearly 54.
616 SCIRRHOUS CAKOBR.
without any apparent increase in a cancer ; and the progress even of
ulcerated cancer is, in such patients, sometimes scarcely perceptible, even
in the lapse of years. On the other hand, cases are found sometimes of
most rapid increase. I saw such an one last summer. A hard cancer
grew in five months from the size of the tip of a finger to a mass five
inches in diameter. This was in a woman 32 years old, in whom the
disease began while she was suckling, and immediately before, even while
suckling, she again became pregnant. Extensive and speedy sloughing
followed this rapid growth, and she died in seven months from the first
observation of the disease.*
We may very probably connect this singular rapid progress of a hard
cancer with the condition of determination of blood to the breast in which
it occurred, and to the early age of the patient, — for, as a general nde,
though malignant tumors may, in their plan and mode of growth, de-
viate never so widely from the normal tissues, yet for their rate of increiae
they are dependent, in a certain measure, upon the supply of blood, and
the general activity of the nutritive processes. Hence it needs to be
always borne in mind, in questions of operation, that among the canoe^
ous they who seem most robust may succumb most quickly ; while the
aged and withered commonly live longest and with least discomfort.
The increase of a hard cancer appears to be by gradual snperadditioii
of new particles on the surface of the mass already existing, and in the
interstices of the tissue immediately bounding it. It is a nice question
to determine how far from a mass of cancer already formed, say, in the
breast, the parts to be next added to it will be formed. Practice pro-
fesses to have settled this in the rule that the whole mammary gland should
be removed when only a portion of it is manifestly cancerous. But what-
ever be the facts on which this rule is founded, — and I believe they arc
enough to justify it, — they may be explained by the advantage resulting
from the removal of all the part in which the cancer would be most
apt to recur : they do not prove that cancer is already present in the
part of the breast that appears healthy. It is, indeed, rare to find more
than one cancerous mass in a mammary gland. I do not remember to
have seen it more than four times in about 100 cases ; and in one of these
the second cancer appeared to have been detached, not to have grown
separately, from the principal mass. I have looked with microscopic help
at the tissues close by a hard cancer, and have found, I think, cancer-
cells one or two lines distant from the apparent boundary of the chief
mass, as if the disease had already begun where neither the naked eye
nor the finger could have discerned it. Beyond this little distance I have
not found reason to believe that cancerous matter in any form exists in the
parts of a cancerous mammary gland that appear healthy.
After an uncertain time and extent of growth of hard cancer, Ulcera-
* This was the same case as that related by Mr. Gray, in the Proo. of PathoL Soc^ 1S51-3,
p. 444.
ULCERATION. 517
nox almost constantly follows. This may ensue in various ways ; it may
be accelerated or retarded by many extraneous circumstances, according
to which, also, its characters may vary ; but there are two modes of ulcera-
tion which are especially frequent, and are almost natural to the course
of the cancer.
In one of these the ulceration begins superficially, and extends inwards;
in the other the changes leading to ulceration begin in the substance of
the cancer, and thence make progress outwards.
The superficial mode of ulceration is commonly observed when the
cancerous growth has slowly reached and involved the skin. The best
examples are those in which the hard cancer first affects a border-lobe of
the gland. From this, as it grows, it extends towards the skin, occupy-
pying as it extends, the subcutaneous fat, and all the intervening tissues
(fig. 82). The skin, as the cancer approaches, whether raised or depressed
towards it, adheres closely to its more prominent parts, or to its whole
surface. It becomes now, while cancerous matter infiltrates it, turgid
with blood, thin, tense, and glossy, florid or dusky red, or livid or pale
ruddy brown : the congestion does not extend far, nor very gradually fade-
out, as in an inflamed integument, but is rather abruptly circumscribed,
just beyond the adhesion of the skin to the cancer.
In the next stage, the surface, in one or more places, appears raw,
as if excoriated ; or else, by some sudden stretching, it is cracked ; or a
thin yellow scab forms over part of it, which, being removed, exposes an
excoriated surface, and is soon reproduced. After a time the excoriated
or the cracked surface appears as a more certain ulcer ; scabs no longer
form, but a copious, acrid, thin fluid exudes. The ulcer is apt to extend
very widely ; and if there have been more than one, they soon coalesce ;
but they very rarely extend deeply, and their surfaces rarely appear
otherwise than pale, hard, dry, and inactive. The growth of the can-
cer continues, as usual, after the ulceration ; and with the growth and
the involving of more skin, the ulceration is generally commensurate.
Now the ulcer thus formed has, in itself, no so-called specific charac-
ters : examined by itself, it has not the features assigned to the cancer-
ous ulcer ; we recognise its nature through that of the mass beneath
it. And yet there is much in the occurrence of this form of ulceration
that is characteristic. For we may always notice that, though it is
effected as if by the destruction of the skin, and is not unlike the ulce-
ration that ensues over a great firm tumor that has stretched the skin
to its extreme of tolerance ; yet its occurrence is determined, not by the
bulk of the cancer and the tension of the skin, but by the adhesion and
confusion of the skin with the cancer. As the cancer approaches the
skin, so the skin, without any stretching, becomes thinner and thinner;
then its residue becomes cancerous ; and then, at length, it is excoriated.
The cancer, exposed through the superficial ulcer, is not apt to be exu-
berant: it does not become or throw out "fungous growths," it manifests
518 SCIRRHOUS OAKCER.
no peculiar tendency to further ulceration. Granulations* of ordinarj
aspect, or such as are only too pale and hard, may coyer it, and it may
often scab, or even skin over ; or, if it deepen itself, it may be with no
assumption of cancerous shape, but like a common chronic ulcer deep-
ening by sloughing or acute inflammation.
Far different from this, though sometimes superadded to it is the form
of ulcer of the breast which begins in the substance of the caocer. I
will not now enter upon the discussions about the softening of cancen
(as a normal tendency of their structure), or upon those about their inte-
rior suppuration : I will only state that, in certain cases of hard cancer,
we find cavities filled and walled in with softened and disintegrated can-
cerous matter. In these, the dull, ochre-yellow, soft material, consists
mainly of degenerate cancer-cells and their dAris. It may be mii^kd
with an ill-formed pus; and as these mingled materials increase and
enlarge the cavity, so, finally, they are discharged by ulceration. Their
discharge leaves in the solid mass of cancer a deep excavated ulcer, t
cavity like that of a widely open abscess, except in that it is all walled
in with cancerous matter, the remains of the solid mass. Then, as tin
walls of this cavity ulcerate on their internal surface, and at the margin
of the opening into it, so their outer surface is increased by superadditica
of the cancerous matter ; i, e, as one part of the cancer wastes, by ejec-
tion of its ulcerating surface, so is another part increased. Hence the
ulcer constantly enlarges : but the ulceration does not destroy the cancer;
that increases the faster of the two, extending more and more, both
widely and deeply, and involving different tissues more and more con-
tinually, to the end of life. In all its course it yields a thin, ichorooa,
and often irritating discharge, that smells strongly, and almost peculiarly.
In all its later course, when not disturbed, this form of canoeroiu
ulcer has certain characteristic features, which are chiefly due to the
concurrent processes of ulceration at one surface, and of predominating
fresh formation at the other surface, of the cancer. Thus the edge of
the ulcer is raised by the exuberant formation of cancer iu and beneath
the boundary of skin : the exuberance of the growth necessarily everts
the margin, which is too rigid to stretch ; and the margin thus raised
and everted is hard, nodular, and sinuous, because the growth under it,
like the primary cancer, is often formed after a knotted tuberous plan.
The base of the ulcerated cavity is similarly hard and knotted, or
covered with hard, coarse, cancerous granulations. Lastly, when we cat
through such an ulcer, we divide a thick layer of cancer, infiltrated in
the subjacent tissues, before the knife reaches any normal structures.
It would be vain to try to describe all the various and dreadful forms
of ulcer that follow the acute inflammations and sloughings of scirrhous
cancers, or all the aggravations of the disease by hemorrhage from the
* These granulations are formed of cancer-structures ; yet, let it be observed, they take tb«
shape and construction of such as arc formed ih the healing of any oommoD nicer.
HEALING. 519
nkerating surface, or by obstmctions of the lymphatics or the veins. As
I passed by the effects of these accidents of the disease, in describing its
itractiire, so, much more, must I now. Only I would state that these
are the events which produce, in cancerous patients, the most rapid and
Ae most painful deaths. When inflammation is averted from it, a can-
eerous ulcer may exist very long, and make slow progress, without
extreme pain or disturbance of the health ; it may be no worse a disease
Am the ^' occult" cancerous growth ; and ten or more years may pass
with the health scarcely more impaired than at the beginning. Sir B.
Brodie* has related two such cases ; and I may add to them one which I
bare lately seen in a cook, who has for eight years had hard cancer of
Ae breast. During five of these years it has been ulcerated, and yet
none of those with whom she lives is aware that she is diseased.
Such cases of arrest of cancer are, however, very rare ; they are only
rare exceptions to the general rule of that progress towards death, the
rate of which is far less often retarded than it is accelerated by such
accidental inflammations of the cancer as I have already referred to.
Still more rare are the exceptions in which an ulcerated cancer heals.
Such cases, however, may be met with, especially among the examples
of the more superficial ulcer. The ulcers may be skinned over (as any
common ulcer usually is), and the cancerous mass beneath it may waste
and be condensed, so that the disease may be regarded as obsolete, if not
cored.
The conditions under which this healing and regress of the ulcerated
cancer may take place are, I believe, as yet quite unknown. In the
following case they seemed to be connected with the development of tuber-
eoloos disease, as if the patient's diathesis had changed, and the cancer
had wasted through want of appropriate materials in the blood.
I removed the breast of a woman 25 years old, including a large
mass of well-marked scirrhous cancer of three months* duration. She
appeared in good general health, and could assign no cause for the dis-
ease. The progress of the cancer had been very rapid ; it had lately
affected the skin near the nipple ; and all its characters were those of
the acute form. The axillary glands had been enlarged and hard, but
had subsided with rest and soothing treatment. Six months after the
operation, and after the patient had been for four months apparently
well, cancerous disease reappeared in the skin about the scar, and in the
axillary glands. In the skin it rapidly increased ; numerous tubercles
formed, coalesced, and ulcerated; and the ulceration extended till it
occupied nearly the whole region of the scar, and often bled profusely.
Thus the disease appeared progressive for twelve months after its reap-
pearance ; but at the end of this time the ulcer began to heal, and in the
next six months a nearly complete cicatrix was formed ; only a very
small onbealed surface remained, like an excoriation covered with a scab.
* Lectures on Surgery and Pathology, p. 211.
TkU book U the J)-
520 SCIRRHOUS CAKOXR.
The disease in the axilla, also, nearly subsided ; one hard lump alone
remained of what had been a large cluster of hard glands. But even
during and after the healing of the cancerous ulcer she lost strengtb,
and became much thinner, and at length, gradually sinking, she dded,
nearly two years after the operation, and six months after the cancer bd
so nearly healed.
In the examination after death I found in the situation of the scar of
the operation, a low nodular mass of the very hardest and densest cancer
extending through the substance of the scar and the pectoral muscle, and
nearly all covered with thin scar-like tissue. In the axilla was one bard
cancerous gland, and in the liver were many masses of cancer as dense
and hard as that on the chest. In all these parts the cancer-structures
appeared to be condensed and contracted to their extreme limit.
The lungs contained no cancer, but were full of groups of gray succo-
lent tubercles and grayish tuberculous infiltration in every part except
their apices, where were numerous small irregular tuberculous cavities.
The other organs appeared healthy.
The contrast was very striking, in this case, between the appearances
of active receixt progress in the tuberculous disease, and of the opposite
course in the cancerous disease found after death ; and I can hardly
doubt that, during life, the progress of the one had been at first coind-
dent, and then commensurate, with the regress of the other.
But leaving, for the present, the questions of the relations between
cancerous and tuberculous disease, I would observe that this case illus-
trated the two modes of healing that may occur in cancer ; namely, the
formation of a scar over the ulcer, and the shrivelling of the cancerous
mass. The first appears to be accomplished according to the ordinary
method of the healing of ulcers : the second is probably similar to the
contraction and induration of deposits of inflammatory lymph. So
far as I know, the process of superficial healing has not been minutely
examined in relation to the changes ensuing in the elementary structures
of the cancer. Only, one sees cuticle forming on the surface of appa-
rently cancerous granulations. In the process of shrivelling the can-
cerous mass becomes smaller, denser, drier, and harder ; it contracts and
draws in more tightly the adjacent parts ; it yields no turbid "juice,"
but a thin serous-looking fluid may be scraped from it in very small
quantity. One finds in such fluid, sparingly distributed, cancer-cells
and nuclei, with molecular and granular ddbris-like matter ; but (in the
breast) the chief mass of the shrivelled cancer seems to consist of the
proper tissues of the organs, indurated and condensed. We cannot doubt
that, during such a change, cancer-cells and other elemental structures
are absorbed; but the changes preparatory thereto are not, I think,
satisfactorily explained.*
* The whole process is minutely discussed by Virchow, in his Archiv, B. L p. 185, et feq.
CACHEXIA. 521
Sach may serve as a general history of the progress of a scirrhous
cancer in the breast. Let me add a brief notice of the pain, cachexia,
and some other of its accompaniments.
Among the many inconstancies in the life of cancers, none, I think,
k more striking than that which relates to the attendant pain. One sees
eases, sometimes, that nin through their whole career without any pain.
In a case of deeply-ulcerated cancer of the breast, the patient, who had
also a cluster of cancerous axillary glands, begged that the disease
might be removed, but only because it was ^^such a terrible sight." It
had never once given her the least pain. In another case a patient, from
whom a cancer involving the whole mammary gland was removed, was
quite unaware of any pain or other affection in her breast till, a few
weeks before the operation, some of her friends observed its diminished
siie. The largest hard cancer of the breast that I have yet removed'
was equally painless. Another patient, who died with rapidly progressive
and ulcerated cancer, had not a pain in its two years* duration.
On the other hand, we sometimes meet with cases that quite exemplify
ihc agony which is commonly regarded as the constant accompaniment
of hard cancer. In such a case the patient could ^'wish herself dead,"
for the sake of freedom from the fierce anguish of her pain, — pain as if
a hot dart were thrust swiftly through her breast, or right through' her
chest, — ^pain, startling with a sudden pang, and then seeming to vibrate
till it fades out slowly ; or, sometimes, more abiding pain, likened to the
baming and scalding of hot water or of molten lead. With such resem-
blances as these do patients strive to describe the agonies, which are in-
deed beyond description, and of which the peculiar intensity is perhaps
best evidenced by the fact, that the sufferers almost always thus liken them
to some imaginary pain, and not to anything that they have felt before.
The memories of those who have suffered even the pains of child-birth
supply no parallel to that which is now endured ; the imagination alone
cui suggest the things with which it may be compared.
Now, although both these classes of cases be exceptions from the
g^eral rule concerning the painfulness of cancer of the breast, yet they
are interesting, both for their own sakes, and because they illustrate the
nature of the pain attending tumors; they show that it is, in great
measure, independent of the merely mechanical condition of the parts ;
that it is due not to pressure on the nerves, or to their tension or displace-
ment, but rather must be considered as a subjective sensation, a neuralgia
due to some unknown, morbid state of nerve-force. That this is so is
nearly sure from the fact, that if we compare the most painful and the
least painful cancers with each other, we may find their structure and
relations exactly similar. Any of the forms that I have described
may in one case be attended with intense pain, in another may exist
without discomfort. They may present no other difference than the
immense difference of painfulness.
522 8CIRBHOU8 CAKCBB.
However, as I have said, both the very painful cancers and those that
are always without pain are exceptional cases. The more general nde
seems to be (1), that in the early part of its course (for instance, in ordi-
nary cases for the first year or year and a half), the hard cancer of the
breast is either not painful at all, or gives only slight and occasional ptin^
or is only made painful by handling it ; (2) that during this time, its ptm
has usually no peculiar character ; is not generally lancinating, but more
often, and especially after manipulation, is dull and heavy; (3) that after
this time the cancer becomes progressively more painful, and the pain
acquires more of the darting and lancinating character ; (4) that the
pain is generally increased when the cancer grows quickly, and more
constantly when it is inflamed and ulcerating, or about to slough: (5)
that the pain is yet more intense when the cancer is progressively ulce-
rating, and now adds to its lancinating character, or substitutes for it,
the hot burning or scalding sensation.
With the advance of the local disease the signs of general disorder of
the health usually increase ; and the cancerous ^^ cachexia," which maj
at first have been absent or obscure, is established. It would be verj
difficult to describe this state exactly, and much more so to analyze it
The best description of its most frequent characters is, I think, that bj
Sir Charles Bell:* — "The general condition of the patient is pitiable.
Suffering much bodily, and everything most frightful present to the ima-
gination, a continual hectic preys upon her, which is shown in increasing
emaciation. The countenance is pale and anxious, with a slight leaden
hue; the features have become pinched, the lips and nostrils slightly
livid ; the pulse is frequent ; the pains are severe. In the hard tmnors
the pain is stinging or sharp ; on the exposed surface it is burning and
sore. Pains, like those of rheumatism, extend over the body, especially
to the back and lower part of the spine ; the hips and shoulders are sub-
ject to those pains. Successively, the glands of the axilla and those
above the clavicle become diseased. Severe pains shoot down the arm
of the affected side. It swells to an alarming degree, and lies immoT-
able.
"At length there is nausea and weakness of digestion: a tidding
cough distresses her ; severe stitches strike through the side ; the poise
becomes rapid and faltering ; the surface cadaverous ; the breathing anx-
ious; and so she sinks."
This vivid sketch is generally true of, perhaps, a majority of the
cases of hard cancer of the breast ; but I doubt whether any one of the
signs of cachexia here indicated is constantly present. Even emaciation
is not so ; for many die, exhausted by the suffering and discharge, in
whom fat is still abundant, or appears even increased about the cancer
itself. This want of constancy adds greatly to the difficulty of analys-
* Medico-Chirurgical Transactions, xii. 223.
MULTIPLICATION. 628
iDg the phenomena of the cachexia. We can see little more than that
they include two mingled groups of symptoms : of which one may be
cdled ^^ primary," depending on the increasing morbid and peculiarly
einoerous condition of the blood, and the other ^^ secondary," depending
on the local disease, and the effects produced on the blood by its pain,
discharge, hemorrhage, and various accidents. In the confusion of symp-
toms thus arising analysis seems impossible.
The last concomitant of the scirrhous cancers of the breast, that I
need now speak of, is their multiplication ; but I will here only enume-
rate the methods in which this may happen ; for its explanation belongs
to the general pathology. These, then, are the methods : —
First, and most frequently, the disease extends to the lymphatic ves-
sels and glands ; or to their contents ; for it seems most probable that,
M Mr. Simon has suggested, its progress is along the continuity of the
lymph from the breast to the glands.
(2.) Next, I think, in order of frequency, are the multiplications of
the cancer in the same region ; not, indeed, in the same gland, but in the
akin and muscles near it, and then in areas gradually widening round it.
(3.) It is less frequent for the scirrhous cancer to appear secondarily
in the similar tissue of the opposite breast. Indeed, its multiplication^
if it may be so considered, is less frequent in this direction than in that
of some organs of more different texture, especially the bones, the liver^
and the lungs. These, among parts distant from its primary seat, are
by far the most frequent seats of secondary disease ; but with these, or,
much more rarely, alone, nearly every tissue has been found affected.*
The structures of many examples of these secondary cancers are al-
ready described (p. 503, &c.). It is often said that the cancers which
appear as secondary to the scirrhous of the breast arc of the medullary
kind ; an error which I think must have arisen from the belief that the
Bciirhous cancer is always fibrous. I have already explained that it very
rarely is so, and only appears to be so when it grows in parts containing
fibrous tissue; and that what has been generally deemed the fibrous
structure of the cancer is usually that of the organ in which it is seated.
The secondary cancers are, usually, in all points conformed to the pri-
mary, and consist, like them, essentially of cells compacted into a hard
mass. They may appear fibrous when growing in fibrous organs : but^
inasmuch as their more usual seats are in organs that naturally contain
little or no fibrous tissue, they are more commonly formed of cell-struc-
tures alone. The change from hard to soft cancer is rare ; it may, how-
ever, take place, especially in the latest growths ; and it is the best illus^
tration of the affinity between the two forms of the disease.
To end this history of the scirrhous cancers of the breast, I must
* M.Lebert has given a table of the relative frequencies of secondary cancers in different
organs after primary disease in the breast. It is drawn from 23 autopsies. Mr. Birkett
hB» given a similar table of 37 cases examined after death.
524 SCIRRHOUS OAKCBR OF THE BREAST.
speak of their duration. There is a striking contrast between the certain
issue, and the uncertain rate, of their progress. Gases are on record in
which life has been ended in four months ; and others in which it hu
been prolonged to twenty-five years ; but I am not aware of a single
clear instance of recovery: of such recovery, I mean, as that the patient
should live for more than ten years free from the disease, or wiUi the
disease stationary.
The average duration of life, from the patient's first observation of
the disease, is a little more than four years. In 66 cases, tabulated with-
out selection, I find it something more than 49 months.'^
Among Gl of tfiese 7 died in between 6 and 12 months.
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The cases are too few to allow of many conclusions : but they suffice
at least to show that the average duration of life in these cancerous
patients would afibrd a wrong estimate of the probable duration of life
in any single case ; since the number who live beyond the average is fcr
less than that of those who die within it, and the mean average is raised
by the lives of those few who survive long periods.
It seems at present impossible to estimate many of the condiUons
which determine the duration of life ; but none among them seems more
weighty than the age at which the disease commences. There are, in-
deed, many exceptions to the rule, yet, on the whole, the earlier the dis-
ease begins the more rapid is its course. Thus, among those who lived
not more than 18 months, I found that the average age at which the
disease was first observed was 43 years. Among those who lived be-
tween 18 and 26 months, it was 51 years ; and among those who lived
between 3 and 8 years, the average at the commencement of the disease
was 56*7 years.f
• I say " something more," because I have reckoned in the cases of five patients who are
still living more than 49 months from the first observation of the disease. In the first table on
the next page six similar cases are reckoned with those from which the general average is
derived. Of the patients already dead, the average duration was, for those in this table^
49*30 months ; for those in the next table, 489 months. The difference is far less than I
believed it to be when the lecture was delivered ; I was deceived at that time by using too
small a number of cases, and a table containing some cases that were recorded only because
they were examples of rarely long life.
t The average for those who lived more than 8 years was only 45 years. But this will
not materially invalidate the rule as stated above, if, as I suspect, these long lives owe their
unusual duration to something interfering with the more normal progress of the disease; and
if, as is also probable, the deaths from cancers, commencing in those whose average age is
near 60, are oAen prevented or accelerated by tlie other diseases which destroy to large a
proportion of persons Uving to xViaX a^e.
BFFKCT8 OF KBIIOYAL. 626
In all the cases from which the foregoing deductions were made, the
bease ran its course uninterrupted by operative treatment.
In 47 cases, in which the cancer was once or more removed by opera-
tbn, the average duration of life, after the first observation of the dis-
ease, was again something more than 49 months. I believe, therefore,.
that tiie removal of the local disease makes no material difference in the
average duration of life ; but if the following table be compared with
that of the preceding page, it will seem probable that the course of the
more rapid cases is retarded by the operation. Among 41 of those pa-
tients who are already dead,
4 died in between 6 and 12 months.
4
M
tf
12
«
18 •*
2
tt
M
18
M
24 «
5
U
M
24
U
30 "
3
tt
U
30
U
36 «
11
tt
U
3
tt
4 yean.
8
tt
tt
4
tt
6 "
2.
tt
M
6
M
8 «
1
M
U
8
tt
10 «
1
«
M
10
tt
20 «
It would seem, I repeat, as if the course of cancerous disease, that
otherwise would be very rapid, were retarded by the removal of the
growth ; for, while in some respects the two tables closely correspond, it
may yet be noticed that the proportion of those who die within two
years is 86 per cent, of those in whom the disease is allowed to run its
course, and only 24 per cent, of those from which the growth is once or
more removed. The number of cases from which this is concluded is
indeed^ small; but other facts might lead us to expect the same, espe-
cially that in general the most rapidly fatal cases are those in which the
local disease has the greatest share in the death.
The constitutional part of the cancerous disease, little, if at all, af-
fected by the removal of the local part, manifests itself by the recurrence
of cancerous growths in or near the seat of operation, or in the lym-
phatics of the breast, or in some more distant part. In 74 cases, com-
prising 21 collected by M. Lebert and 53 by myself, the periods of re-
currence after the operation were as follows : —
Between 1 and 3 months in 23 cases.
u
tt
u Q 1Q u A u
tt
tt
u n A « • 1 M
tt
u A B U O U
3
6
tt
22
6
9
tt
s
9
12
u
6
12
24
u
7
2
3
3
4
years in
u
3
1
4
6
u
2
6
8
u
2
Neither of us has yet met with a case in which recurrence was de-
layed beyond eight years.
The table confirms the view that the removal of the local has little
526
SCIRRHOUS CANCER OF THB BRBA8T.
influence on the constitutional element of the disease ; for even if we
believe that many of the cases, reported as recurrences between 1 and
3 months, were examples of continuous, rather than of recurrent, local
disease, still the small proportion of cases in which recurrence wag de^
layed more than twelve months after the operation might suggest the
belief, that after an operation the constitutional disease continues and is-
creases, till it manifests itself in recurrent local disease, in about the same
time as it might have appeared in some secondary cancer, if the opera-
tion had not been performed.
The recurrent local disease appears generally to be less intense thin
the primary. This is probable, both from the fact mentioned at page
525, respecting the smaller proportion of rapidly fatal cases in thoee
submitted to operation, and from the fact that when recurrent cancen
arc removed, the second recurrences sometimes ensue more slowly than
the first did. In 12 eases in which recurrent cancers of the breast were
removed I find that the period of second recurrence, i. e. the interval
between the second operation and the reappearance of the disease, was
:
Between 1 and 3 months in 4 cases.
tt 3 " 6 " 3 "
a 6 " 12 « 1 "
»» 2 ** 3 yenrs in 2 "
tt 6 « 7 " 2 •*
And, among these late-recurring cases, is one to which the first recur-
rence was after 24 months, the second after 60 ; another of first reciD>
rence in 12 months, and second in 84 ; and another of first recurrence
in 2 months, and second in 24.
It is believed by some that the cancer of the breast (and they would
say the same of other cancers) is in the first instance a local disease ;
and that the constitutional disease which is manifested by recurrence after
operation, or by multiplicity of cancers, or by cachexia, is the conse-
quence of the slowly-acting influence of the local disease. If this
opinion were true, we ought to find that the average interval between re-
moval of the disease and its recurrence bears an inverse proportion to
the time of duration of the cancer before removal. No such proportion,
however, exists : nor does it even appear that recurrence is, on the whole,
later after early, than after delayed operations. The following table
shows the times of recurrence in 56 cases, in which the removal of the
cancer was efiected within various periods, from three months to fonr
years, after its first appearance : —
TIME OF OPERATION.
Under 3 montlis,
Between 3 and G months, .
" 6 « 12 "
»• 12 « 24 «
« 24 " 48 "
TIME OF BECUaaKHCSS.
Within Between More Umb Na of
6 months. 6 it 12 months. IS montlis. Cmm.
2 2 8
2 2 9
4 5 14
1 3 13
3 3 19
5
5
9
7
BFFBCT8 OF BEIIOYAL. 627
The fdlowiDg table shows that the duration of life is not greater after
early than sfter late operations : but this is, doubtless, because the most
icote cancers are, on the whole, the most early rem9Ted : —
ATengv darstkm Nambtr
TIbm oCtficattoa. of life after the of
operation. eaaai.
Under 3 RMnthfi, 20 mooths 4
Between 3 and 6 months, 12 ** 6
- 6 " 12 * " 39 « 8
« 12 « 24 " 17 « 8
« 24 « 4S *» 21 •* 5
Lastly, I can find, in the cases I have collected, no confirmation of
the received (and possibly true) opinion, that when some of the axillary
tymphatie glands are cancerous, and are removed with the cancerous
breast, the recurrence of the disease, and its fatal termination, are more
speedy, than after operations in which the breast alone is removed, the
glands appearing healthy. In 20 cases of removal of the breast alone,
the average time of recurrence was eight months, and that of death
twenty-four months, after the operation : while in 10 cases of the removal
<yf the breast with some axillary glands, the recurrence ensued, on an
average, in thirteen months, and the death in twenty-four months, after
4he operation.
I find as little clearly recorded evidence for the similarly unfavorable
Vfinion generally entertained of the efiects of the removal of cancers
adherent to the skin, or already ulcerated. I would be far from holding
that these opinions are incorrect ; but their truth is not yet proved ; and
it IS not supported by such cases as I have been able to collect. The
pecorrences and deaths after these '^unfavorable" cases are indeed sure
and speedy ; but I am not yet clear that they are more so than those
are wldch follow the operations that are undertaken in some of what
are deemed the most favorable cases.
The foregoing facts, relating to the influence of the removal of can-
iceieus breasts, on the progress of the disease, and on the duration of life,
msgr he considered from two points of view — the pathological and the
]»raetical. Mere pathology may study these operations as so many ex-
periBents for determining the mutual influences of the local and the con-
stitBtional elements of the cancerous disease ; or, the qucsi^tions enter-
tained by some respecting their priority ; or, the share taken by each in
destmying life. I trust that the tables I have given may be of some
avaii for the settlement of these and other similar questions, to which I
AbUI again refer in the concluding lectures. But at present, few of the
facta, which mere pathology can gather from inquiries such as these, are
sufficiently clear or pronounced to serve for guidance in the practice of
sorgeiy, in which we have to deal with single cases, not with many at
onee, and in which each case presents many questions that cannot yet be
rndtwi by general statements.
528 SCIRBHOUS CAKCER OF THB BBBA8T.
In deciding for or against the removal of a cancerous breast, in any
single case, we may, I think, dismiss all hope that the operation will be
a final remedy for the disease. I will not say that such a thing is impos-
sible ; but it is so highly improbable, that a hope of its occurring in toy
single case cannot be reasonably entertained.
The question, then, is, whether the operation will add to the length,
or to the happiness of life. The conclusion from the foregoing tables
might be that the length of life would be the same, whether the local
disease were removed or not. But such a conclusion cannot be uncon-
ditionally adduced for the decision in a single case. The tables do not
include cases in which the operation was fatal by its own consequenoea: '
. yet these are not few. In 285 operations for the removal of canoerooa
and other diseased breasts, I find 28 deaths : and probably this morta£ty
of 10 per cent, is not too high an estimate, — at least, fcnr the results of
hospital practice. We have to ask, therefore, whether it is probable
that the operation will add to the length or comfort of life, enough to
justify the incurring this risk from its own consequences.
I cannot doubt that the answer may be often a£Srmative. — 1. In cuei
of acute hard cancer the operation may be rightly performed : thon^
speedy recurrence and death may be expected, its performance is justified
by the probability (see p. 525) that it will, in some measure, prolong life,
and will save the patient from dreadful suiTering. 2. On similar gronndSi
the operation seems proper in all cases in which it is clear that the local
disease is destroying life by pain, profuse discharge, or mental anguish,
and is not accompanied by evidences of such cachexia as would make the
operation extremely hazardous. 3. In all the cases in which it is not
probable that the operation will shorten life, a motive for its performance
is afibrdcd by the expectation that part of the remainder of the patient's
life will be spent with less suifering, and in hope, instead of despair; for
when they are no longer sensible of their disease, there are few cancer-
ous patients who will not entertain and enjoy the hope of long immunity,
though it be most unreasonable and not encouraged.
On the other side, there are many cases in which the balance is clearly
against the operation. — 1. In well-marked chronic cancers, especially in
old persons, it is so little probable that the operation will add to either
the comfort or the length of life, that its risk had better not be incurred.
These are, indeed, the cases in which the operation may be longest sur*
vived ; but they are also those in which, without operation, life is most pny-
longed and least burdened. 2. In cases in which the cachexia, or evident
constitutional disease, is more than proportionate to the local disease, the
operation should be refused : it is too likely to be fatal by its own con-
sequences, or possibly by accelerating the progress of cancer in organs
more important than the breast. On similar grounds, and yet more cer-
tainly, it should not be performed when there is any reasonable suspidcm
of internal cancer. 8. If there be no weighty motives for its perform-
XBDULLART OANOEB. 629
ioce, the operation Bhoald be avoided in all patients whose general
keaJth (independently of the cancerous diathesis) makes its risk unusu-
iUy great; — in all, for example, who are very feeble, very fat, over-fed,
intemperate, or in any of those conditions which make persons unfavor-
able subjects for surgical operations.
The abov6 rules leave unconsidered a large portion of the cases of
hard cancer of the breast ; and I fear that, at present, no other statement
can be made concerning the cases which do not fall within such rules as
these, than that each must be decided, by weighing the probability that
the operation will prove fatal, or, by weakening the patient, will accelerate
the progress of the constitutional disease, against the probability of its
adding to the comfort, and thereby to the length of life. The first of
these probabilities must be estimated by the same general principles
(vagae as they are) by which we reckon the dangers of all capital opera-
tions : the estimate of the second may be, I hope, assisted, though it
eannot be settled, by the evidence collected in the foregoing tables. In
every case we should keep in view the twofold method of destruction by
this disease. It may destroy life by its consequences as a local disease ;
or by its primary and specific cachexia, which may be progressive inde-
pendently of the local affection. Usually, indeed, its local and constitu-
tional parts mutually affect and aggravate each other, and both contribute
to the fatal issue : but, since they do not always contribute in the same
proportions, our object should be to ascertain, in each case, which will
oontribute most, — the local disease, which the operation can remedy, or
the constitutional, which, if at all affected by the operation, may be made
more intense.
LECTURE XXXI.
MEDULLART CANCER.
PART I.— ANATOMY.
From the long list of names which Dr. Walshe, with his usual pro-
found research, has found assigned to this disease, I select that of
Medullart Cancer, because it 'has been sanctioned by the longest usage
and by many of the best pathologists. It is true that the term " medul-
lary" is vague and unmeaning ; yet even this seeming defect may have
some advantage, since, after long custom, we may now employ the word,
a9 we do inflammation, cancer, and many others, without any reference to
their original meaning, and, therefore, without any danger, of too much
limiting our thoughts to the likenesses which they express. The very pre-
cision and fixity of such terms as encephaloid, cerebriform, cephaloma,
and the like, are objectionable, by directing the mind to a single character
84
580 lIBliULLABT CAHCB&.
of diseased structures, and that an inconstant one; for Uie likenento
brain is observable in only a portion of the tumors to which the nameioC
brain-like and its synonyms are applied.
The boundaries of the group of medullary cancers can bo cmly yaguelj
drawn ; for, although, on the whole, and as a group, they have peculiari-
ties, both of structure and of history, which sufficiently distinguish ihm
from the scurhous and other cancers, yet, define them by whateier
character we may, a series of specimens might be found filling eTerj
grade between them and each of the other chief forms. The term ^^soft
cancer," often applied to them, expresses their most obvious, though not
their most important distinction from the scirrhous or hard cancers, and,
used comparatively, it might, for the present, suffice for the definition of
the group. But, in the group thus defined, there are induded miny
forms that appear widely different from each other; and there is, u
Bokitansky has well said, no disease of which the examples present more
deviations from any one cardinal character. It might be right to arrange
the examples of some of these deviating forms under distinct tides ; bnt^
at present, it may be more useful to make no other division of the groop^
than into such as may be called, respectively, 8oJi and farm medoDaiy
cancers. In any large series of specimens, the softer kind would consti-
tute about two-thirds, the firmer about one-third of the whole number.
The former would include such as are described as encephaloid, btaii-
like, milt-like, pulpy, placental, &c. ; the latter would be such as haT6
been called mastoid, solanoid, nephroid, apinoid, ^c.'^
Certain transitional specimens would be found in the series, whick
might be arranged in either division, or between the two; but these,
though they may prove that there is no specific distinction between the
two chief divisions, do not invalidate the utility of speaking of them
separately.
The medullary cancers, whether soft or firm, may grow either as
separable tumors, or as infiltrations. In the former condition, they are
most frequent in the intermuscular and other spaces in the limbs, in the
testicle, the manmiary gland, and the eye : rarely, they are thus found
in the bones. In the latter condition, they most frequently occupy the
substance of the uterus, the digestive canal, the serous membranes, the
periosteum, and the bones.
We have, herein, the first point of contrast, in addition to that of th^
consistence, between the medullary and the scirrhous cancers. The latter
are almost always infiltrations of natural parts : the former appear, m
nearly equal frequency, as infiltrations, or as distinct growths, of cancer-
substance.
The contrast is equally marked between them in regard to their
* I believe, also, that many examples of ^ albuminous sarcoma*' hava been flna mcdidliif
cancers.
SOFT IIBDULLART CAKOBR. 681
mpective seats and allocations. Of every 100 primary hard cancers, I
belieye that not less than 95 would be found in the breast ; and there is
BO other organ in which they are not very rare. But, among 103 tabu-
lated instances'^ of medullary cancer in external parts, the seat of primary
fiaease was in the
Testicle, in 29 cases.
Boaes (most fVeqaently in the femur), . . . ** 21 **
Limbs (especially in the intennuscular spaces), . "19 "
Eyeball or orbit, " 10 «»
Breast, a 7 it
Walls of the chest or abdomen, . ** 5 ^
Lymphatics, u 4 «
Yarioos other parts, » 8 "
103
Let me now, for general examples, describe such soft medullary tumors
•8 often occur in the intermuscular spaces of the limbs or trunk.
To the touch they present a peculiar softness, or a deceptive sense of
the slow fluctuation of some thick liquid ; so that, even to the most expe-
xjenced, their diagnosis from collections of fluid is often doubtful ; and
the adiievement of experience in relation to them is caution rather than
knowledge.
In shape, these tumors are commonly round, oval or spheroidal, fitting
the adjacent parts. But they may be variously lobed ; and when they
are so, these following things may be noticed in them, as well as in the
firmer kinds. (1) Their lobes are peculiarly apt to extend into muscu-
lar and other interspaces, far away from their chief mass. Thus (as I
have seen) in the foot, they may track through the interosseous metatar-
sal spaces, or between bones of the tarsus ; or about the hip or knee, por-
tions may extend deep down to the immediate coverings of the joint ; or,
from behind the ankle-joint, they may reach with the flexor tendons, far
into the sole of the foot. (2) Thus deepening as they grow, parts of these
tumors may acquire unexpected deep-seated attachments. It is frequent
to find them so attached in the neck, even when, in their beginning, they
were easily movable tumors, or such as patients call '^ kernels." (3) In
the same extension, they are much more apt than other tumors are to
grow round,* and completely inclose, important vessels and nerves. I
have thus seen, in one case, the phrenic nerve, in another the pneumogas-
triCy in another the femoral artery, in others the carotid artery and
jugular vein, passing right through medullary cancer which, at first
appeared freely movable and not deeply fixed, and even now had no cha-
racters of infiltration.
* It need hardly be said that this table, containing no cases of medullary cancer in the
JOHntm or other internal organs, is not intended to prove anything concerning the relative
fktquencj of the disease in each part of the body. I know no records by which this could
be proved. Its only purposes are, to show the contrast between niedullary and scirrhous
caneers in relation to their usoal seats in external parts, and to indicate the kind of cases
irom which many of the other tables in this lecture are derived.
582 SOFT IIBDULLART OAVCBB.
The parts around a separable medullary cancer are generally onlyci* ^i
tended, as they might be round an innocent tumor. They are usoalljail j
contracted, or adherent, as those next to a hard cancer are. Eyeandh
a tissue as the glandular substance of the testicle may be cleanly
rated from the surface of a medullary cancer, round which it hai
stretched. Sometimes, however, the parts near the principal tmnor
tain smaller detached growths; and more rarely they are infihratri
with cancer.
When a distinct capsule exists round a medullary cancer, it is jmuBj
composed of fibro-cellular tissue, forming a very thin layer, from the ii>
terior of which partitions may pass, intersecting the substance ef tk
tumor, or investing its several lobes. Generally, such a capsule cootaiM
numerous tortuous bloodvessels ; and is tensely filled, so that^ as soon
it is cut, the tumor protrudes, or, when very soft, oozes out like a
turbid fluid. It is, usually, easy to separate the capsule, or part of it,
from the surrounding tissues ; but it may be closely adherent, and, I thinl;
generally is so in the cases of medullary cancer in the breast.
In section, the soft medullary cancers usually appear lobed ; and tk
partitions between the lobes, derived from the investing capsule, ait
often so complete that they may appear like separate cysts filled with a-
dogenous growths. The lobes are of various sizes and shapes, throoj^
mutual compression ; and they may even seem very differently constmetid.
The material composing these cancers (when not disordered by tk
effects of hemorrhage, inflammation, or other disease) is a peculiar, soft,
cloac-textured substance, having very little toughness, easily crushed tod
spread out by compression with the fingers. It is very often truly briin-
like, most like foetal brain, or like adult brain partially decomposed vA
crushed. Many specimens, however, arc much softer than brain ; vA
many, though of nearly the consistence of brain, are unlike it, being gni-
mous, pulpy, shreddy, or spongy, like a placenta, with fine soft filament;.
Very few have a distinct appearance of fibrous or other regular stmc-
ture.
In color, the material may be white, but most commonly, when tk
cancer is fresh, it is light gray (like the grayness of the retina ifter
death). The tint is usually clear ; it is in many cases suffused with pile
pink or lilac, or with a deeper purple ; and in nearly all, is variegttid
with effused blood and full bloodvessels, whose unequal abundance id
different parts of the tumor produces a disorderly mottled appearaDce-
Masses of bright yellow or ochrey substance also, like tuberde, tre
often found in or between the lobes, as if compressed by them, iriiie
withering and dying in the midst of their growth.
When pressed or scraped, the soft medullary cancers yield abimdtot
^' cancer-juice," a milky or cream-like, or some other turbid, matffiilf
oozing or welling up from their pressed mass. There is no better roagii
test for the diagnosis of medullary cancers than this ia ; and the n^
VASCULARITY. 688
Stance thus yielded is geDerallj diffusible in water, making it uniformly
turbid, not floating in coarse shreds or fragments.
'When the greater part of the softer and liquid substances are thus
pressed out, there remains a comparatively small quantity of tissue, which
appears filamentous, with abundant bloodvessels, and, to the naked eye, is
spongy and flocculent, like the tissue of a placenta. This is the so-
called ^^ stroma" of the cancer ; and it differs from that which, in the
hard cancers, has been so named (p. 500), in that it is not part of the
tissne in which the cancer has its seat, but is probably formed from the
proper blastema of the cancer, and is as truly part of the cancer as the
cells and other corpuscles are.
Such are the most general or normal characters of the soft medullary
cancers. It would be vain to attempt to describe all the varieties to
which they are subject by the mingling of cysts within or on the surface
of their mass ; by hemorrhage into their substance ; by inflammation ;
and by the various degenerations of their proper substance, of the extra-
vasated blood, and of the inflammatory products. There are, I think,
no other ez|imples in which the diseases of the products of disease are
80 frequent, so various, or so confusing as in these.
It is in the medullary cancers alone that the bloodvessels have been
minutely studied ; and in these alone that it is easy to distinguish the
vessels of the cancer itself from those of the organ in which it is seated.
H. Lebert and his colleagues have made numerous injections, displaying
arteries, capillaries, and veins, arranged in networks of various close-
ness, in the substance of medullary cancers of the ovary, omentum,
uterus, and other parts. They have thus disproved the belief that the
vascular system of these tumors is exclusively either arterial or venous.
I may add, that the minute bloodvessels, though, in proportion to their
size, they are thin-walled and easily torn, have the same structures as
tho^ in other new-formed parts.
In some medullary tumors we may notice a remarkable abundance of
even large bloodvessels. Next to the proper cancer corpuscles, they may
appear to be the chief constituent. The cancer that contains them may
thus appear, in many respects, like an erectile tumor, and may often vary
in size, according to the fulness of its bloodvessels. (See p. 544, note.)
When the bloodvessels are chiefly arterial, the whole mass of the tumor
may have a soft full pulsation — a condition which seems peculiarly apt
to be found when the tumor is in part imbedded in, or supported by,
bone, and in part held down by fibrous tissue, such as that of the peri-
osteum.*
To the same abundant vascularity of these tumors we may ascribe
not only their liability to internal apoplectic hemorrhage,t but the great
♦ See Mr. Stanley's paper on the " Pulsating Tumors of Bone," in the Med. Chir. Trans.
ro\. zxTiii. 303.
t It is chiefly to the medullary tumors changed by internal, and prone to external, hemor-
iliage, that the name of fungus hoematodes has been applied.
684 SOFT MEDULLABT OAN0BB0U8 INFILTBATIOX.
bleedings that may ensue when they protrude through ulcers, or an
wounded. I have twice seen the di£Scidty of distinguishing a mednUar;
cancer of the testicle from an hematocele enhanced by the £wt, Uiat
when the swelling was punctured with a trocar, blood flowed in a M
stream through the canula, and continued so to flow till the canula was
withdrawn. The size of the swelling was not diminished, as that of an
hematocele would have been, by the abstraction of the blood; and in
both cases it proved to be a large medullary cancer, very vaBcokr and
very soft. So, when such tumors are cut into in the limbe, the immk
that bleed are far larger and more numerous than in any other tumor,
except the erectile. j
The vessels, moreover, often appear defective in muscular power; for,
as Mr. Hey'*' noticed, the bleeding from them scarcely decreases even
when a tourniquet compresses the main artery of the limb. It is as if thej
could not contract so as to close themselves^ even when the force of the
blood is diminished to the amount with which it traverses the anasto-
mosing channels.
Lastly, we may connect with the great vascularity and rapid growth
of these soft tumors, the large size of the veins near them ; though this
is not peculiar to them, but is found, I think with nearly all tumon
that grow rapidly and to a large size.
Lymphatics have been injected in two specimens of medullary cancer
of the stomach and of the liver, by Schroeder van der Kolk.f In both
instances the vessels passed into the very substance of the cancer.
Of nerves I believe that none have been found in these or in any
other cancers, except such as they have involved in their growth.
The same structures which alone form the separable medullary cancers
may be infiltrated among the natural structures of parts. Thus infil-
trated, the natural structures are expanded and rarefied ; sometimes,
indeed they seem to be, in a measure, thus changed, even before the
cancerous material is deposited among them.| Finally,' most of them
disappear, as in the infiltrations of scirrhous cancer; and the can-
cerous mass may now seem like a separately-growing tumor ; or, when
its material is very soft, it may appear as a quantity of creamy liquid,
collected, like the pus of an abscess, in a defined cavity.
Exceptions to the general rules of the wasting of the infiltrated tissues
are often observed in the fibrous tissues and the bones : both these may
increase during soft cancerous infiltrations.
Medullary cancers may be found in the articular ends of bones, form-
ing distinct tumors aroimd which the walls of the bone are expanded in
a thin or imperfect shell. But more commonly the cancer is infiltrated.
In these cases, it usually occupies, at once, the cancellous tissue, the
• Observations in Surgery, p. 258.
t Lespinasse : De vasis novis pseudomembraDarum, 1842, p. 41. ^ Walshe, L c p. 555.
XBDULLABT 0ANCBR0U8 INFILTRATION OF BONB. 685
wall of the bone, and the periosteum : and it seems probable that the
disease begins simultaneously in all these parts ; or, at least, that when
they are affected in succession, it is not generally by extension from one
to the other. Hence we commonly find that a tumor surrounds the bone,
or, in the case of a flat bone, covers both its surfaces ; and that the portion
of bone thus invested is itself infiltrated with cancer, which is collected
most evidently, but not exclusively, in its cancellous tissue. When a
medullary tumor thus surrounds a long bone, it is usually of unequal'
thickness : when both surfaces of a flat bone are covered, the tumor is
usually biconvex lens-shaped, and is, on both surfaces, of nearly equal
extent.
The periosteum may seem to be continued over a medullary cancer
thus placed ; but is really, with the exception of a thin outer layer, in-
volved in it, and intersects its substance. The intersecting portions of
periosteum chiefly traverse the exterior tumor, extending from the layer
which invests its surface to the wall of the bbne. They form branching
and decussating shining bands, which to the microscope present a perfect
fibrous tissue infiltrated with the cancerous materials. They may, also,
be much increased by growth, so as to give the section of the tumor an
appearance of ^' grain,'' or of a tissue with fibres set vertically on the
bone. Or, the periosteal tissue thus growing may ossify. In this event,
it forms, in a large majority of cases, a light, spongy, and friable growth
of bone, which is like an internal skeleton of the cancer.
Most of the specimens of ^^ spongy" or "fungous" exostoses are such
skeletons of cancers, examined after the maceration and removal of all
the morbid structures that filled their interspaces. The new bone is
■often formed in thin plates and bars or fibres, the chief of which extend
outwards, at right angles to the surface of the bone on which they grow;
they may pass deeply into the substance of the cancer, but they seldom
Teach its outer surface: no medulla is formed with them; and they some-
times form a den^r and harder tissue, like that which belongs to the
osteoid cancers (see p. 466).
In the walls, or compact substance, of the bone thus enclosed by cancer,
it is common to find the laminae separated by cancerous deposit, mingled
with a ruddy, soft material, like diploe. In other cases, the structure of
the walls is rarefied, and converted into a light, soft, and porous or finely
spongy tissue, whose spaces contain cancer-structures. The Haversian
canals, also, may be enlarged ; cancerous matter being formed within
them. Sometimes, a peculiar appearance is derived from an unequal
separation of the laminae of a bone's walls ; large spaces being found be-
tween them like cysts, which may be filled with blood or softened cancer.
Lastly, in the diploe or cancellous tissue, a corresponding state exists.
The soft cancerous material excludes the medulla, and, commonly, its
formation is attended with a disturbed growth of the bony cancelli, so
that they form a finely spongy, dry and brittle structure, or more rarely a
586 FIRM MEDULLART OANOBB.
dense and hard structure, resembling the skeleton of the external mass of
cancer.*
It remains that I should describe the Firm Medullary Cakcebs.
In all their general relations, — as to seat, shape, size, and connexions,
— these correspond with the softer kind. Like them, they may be Bep»-
rate masses, or infiltrated ; may have distinct investing capsules, or maj
extend indefinitely in the proper substance of organs; like them, they
are apt to afiect a certain part or place rather than a single tissue: or
may be the seats of various degeneration or disease : their only pecu-
liarities are in their own structures.f
They are firm masses: not hard, like scirrhous cancers: but firm,
elastic, tense, compact, and moderately tough ; they are as tough as
the more pliant examples of fibrous cartilage, and merge into exact like-
ness to the less hard and more elastic scirrhous cancer. They are not
evidently fibrous, but tear or split as very firm coagulated albumen might
Their cut or torn surfaces appear peculiarly smooth, compact, shining,
and sometimes translucent: in some instances, they are uniform and
without plan ; in some, more regularly and minutely lobed, or even imi-
tating the appearance of any gland, such as the mammary or parotid,
in which they lie. Sometimes they present a strongly marked grain, as
if from fibres: but this results, I believe, from a peculiarly fascicolate
and linear arrangement of elongated cells.
In color, the firm medullary cancers are hardly less various than the
softer kind. They may be pure white ; but more often are white, tinted
or streaked with pale pink, or yellow ; or they may be in nearly every
part buff-colored, or gray ; or these tints may be mingled and mottled
with blood-color, though not so deeply, or with such effusions of blood,
as are frequent in the softer tumors.
On pressure, especially after contact with water, they generally yield
a characteristic creamy or grayish fluid, which sometimes appears
strangely abundant, considering their firmness of texture. In a few in-
stances, however, this character is wanting ; the firmest tumors may give
only a thin, turbid fluid.
Among the points of contrast, in the descriptions of medullary and
scirrhous cancers, is the wider range of variety exhibited by the former
in the original characters of its growths. For the diversities which I have
been describing are not to be referred to changes ensuing in different
stages of the same disease ; the firmer cancers do not gradually be-
* I have twice seen a formation of very firm fibrous substance, like the basis of the osteoid
cancers, in the cancellous tissue of bones that were surrounded with very soft medullary
cancer. I have, also, seen a light brittle skeleton formed in the cancer external to a bone of
which the cancellous tissue was converted into hard osteoid substance.
I" Generally, I think, when they afiect bones, the osseous tissue is apt to soften and waste,
rather than to grow as it does in the soft medullary cancerous afi*ections. Certaioly, the firm
meduIJary cancers rarely have mXeuvaV cke\e\OTv%.
MEDULLARY OANOBB — MICROSCOPIC BTRUOTURB. 687
come soft, nor the soft become firmer ; they are not to be connected
(m the chief yaricties of scirrhous cancer may be) with the acute or
chronic progress of the disease, or with its difierent modes of growth, or
with the difierences of age in which it occurs : rather, the peculiar fea-
tures of each specimen, and of each chief group, appear to be original
and constant, — ^provided they are not aficcted by degeneration or disease.
Now, equal diversities exist in the microscopic structures of medullary
cmcers. There are, indeed, certain characters to which nearly all are
conformed: the microscopic diagnosis is, therefore, seldom difiicult, very
seldom doubtful ; yet many yarieties of appearance need to be learnt,
both that the disease may be always recognised, and that we may, if
possible, hereafter accurately divide the inconveniently large group into
smaller ones. At present such a division is impracticable ; for we can
only sometimes trace a correspondence between a peculiarity of micro-
scopic structure, and one of general aspect, in the tumors ; but it should
be a chief object of future inquiries.
The varieties exist in both the corpuscles and the basis, stroma, or in-
tercellular substance of the cancers.
Among the corpuscles, the most frequent, and that which seems the
normal, form, is that of nucleated cells, which, in all essential characters,
are like those of hard cancer (p. 496, fig. 85). Examples of such cells
may be found in nearly every specimen, although, in certain instances,
other forms may predominate over them. There is, I believe, no mark by
which they may be always distinguished from the cells of hard cancers.
They may be softer, less exactly defined, more easily disintegrated by
water, flatter than the cells of scirrhous cancer are ; but there is in these
things no important distinction. The only constant difierence is in the
modes of compacting, and in the relations of the cancer-materials to the
natural structures in which they are placed. Cells such as, in scirrhous
cancers, are closely placed, with a sparing, firm, intermediate substance.
Oft are tightly packed among the contracted structures of a mammary
gland, are in the medullary cancers more loosely held together, in a more
ftbundant, and much softer or liquid intercellular substance.
The chief varieties of microscopic forms in medullary cancers may be
lescribed as affecting, severally, the nuclei, the cells, and the intercellular
substance ; and it may be generally understood that each peculiar form
nay occur in combination with a predominant quantity of the ordinary
}r typical cancer-structures, or may, in rarer instances, form the greater
part, if not the whole, of a cancerous mass.
(a) Free nuclei, suspended in liquid or imbedded in a soft, nebulous,
}r molecular basis-substance, may compose the whole of a very soft me-
lullary cancer. Appearances of cells may be seen among them, because
)f the adhesion of the basis-substance to them ; and appearances of many-
ludeated cells, when fragments of the basis are detached in which seve-
*al nuclei are imbedded. But certainly, in many instances, formed cells
588 MIDULI.ABT CANOBB — ^HIOBOBCOPIO BTEDOTUEI.
are rare or absent: the Btrncture is as if abundant nuclei were developed
in a blastema, but had not appropriated the several portioos of it, Thid
in further development might be shaped into cells.
The nuclei (fig. 90) are like those of the typioal cancer-oeHfl (p. 496); |
thej are oval or round-oval, having a long diameter of from xiSg to h'd >
^ gg. of an inch, bright, pelluridf perfiectl^ defined,
largely, and often doubly nudeolated. I
It is in the etmctnres thns fonned that the mi- j
nute bloodvessels of cancer may be best ez&mintd I
without injection ; for the soft material in vbidi '
they ramify may be vaehed avray from them, w tt
to leave them neariy alone, and fit for exuniiii-
tion as transparent objects.
(6) Free nuclei (fig. 91), which may be considered as grown or dev*
loped, are often mixed in various proportions, with other canoerBtm-
tures. Some, retaining the usual shape, are much larger than the ave-
rage : others, rarer and more peculiar, are elongated, narrow, strip-like, «■•
date, or pyriform. Some of these are very small, slender, and apparent
of simple structure : others more nearly acquire the size and otfaer cha-
racters of cells. Their contents are not so simple and pelloeid aa tboH
of ordinary nuclei ; in the smaller titej am
darkly dotted or granular, but no contained
^jB\I^:^,^^\ particles appear larger than common nudeofi.
f fy* jt"^ ^ W ^" others, larger, oval, pellucid corpnadea, like
/ ^ f ^Si^' n ^™^" nuclei, are contained; and these Beemto
^f \ ^^ In l"* formed by the enlargment of the nucleoli,.
^t^i e \^v ^^'■^'^ ^^^^ approach or attain the characten
9, S w V °^ nuclei, while the nuclei that contun them
awiii — "'^ ^""^ advanced to the condition of cells. Mo«t
commonly, the cells, that thns seem formed out
of nuclei, are singly nucleated ; but two or three nuclei are found in a
few of large size.
(c) In a few specimens of medullary cancer of the breast (p. 546), and
of the parotid, I have found the chief constituent to be free or clustered
nneloi, of round or round-oval shape (fig. 92), from ^g'nn ^^ soSio **^ *•* ™^
in diameter, well-defined, but not darkly, nebulous or molecular ratlier thu
pellucid, and appearing to contain four, five, or more shining granides,
hut no special or distinct nucleolus. They might have been taken f«r
large corpuscles of inflammatory lymph, but that neither water nor acetic
acid affected them. They wore imbedded in a small quantity of mole-
cular basis, and sometimes airanged in groups, imitating the shapes of
* Fig. 00. Nuclei of soft tnccliillnry cBncer, imbedded in a
withniii concer<ells. Mognifipil 500 times.
t Fig. 91. VariouB grown and developed nuclei of oiedullarf
text. Mngnifled DUO iime«^
molecular bau*-Rib9l>nc«,
I, ai deiciibed in ilu
MBDULLABT OANOEB — MICBOSOOPIO BTBUOTUBE. 689
aebi of glanda. A few of smaller sise, but similar aspect, appeared to
be within cells.
(<2) In a remarkable case, lately at St. Bartholomew's Hospital, a
woman, 67 years old, had two very large and several smaller tumors con-
nected with the skull, a tumor in the lower part of the neck, and similar
small growths in the lungs. They were all very soft, close-textured, white,
or variously covered with extravasated blood, enclosing large cavities
filled with bloody fluid. Except that they yielded no creamy fluid till
after they were partially decomposed, one could not hesitate to call them
medullary cancers. But they were composed, almost exclusively, of
round, shaded nuclei, with three or four minute shining particles, and in
general aspect very like the dotted corpuscles of the spleen. Many of
these were free ; but more, I think, were arranged in regular clusters or
groups, of from five to twenty or more, composing round, or oval, or
cylindriform bodies (fig. 98). A few similar nuclei were enclosed singly
in cells in the cancerous growths in the lungs.
Such are the chief varieties in the nuclei of medullary cancers.
Scarcely less may be found in cells, mingled, let me repeat, in diverse
proportions, with cells or nuclei of typical form, and rarely surpassing
them in number.
{e) Besides those varieties in the shapes of cells, which were described
among the microscopic characters of hard cancers (p. 496), and which
are equally, or with yet more multiformity, found in these, we may note
the occasional great predominance of elongated caudate cells in some
examples of medullary cancers. I have hitherto observed this in none
but some of the firmest specimens of the kind. Many such contain only
typical cancer-cells ; but in some the caudate and variously elongated
cells predominate, and, by their nearly parallel and fasciculate arrange-
ment, give a fibrous appearance to the section of the tumor. The fol-
lowing sketch (fig. 94) is from the cells of a very firm tumor that grew
round the last phalanx of a great toe.J Its cancerous nature was proved
♦ Fig. 92. Dotted nuclei of medullary cancer, described in the text. Magnified 500
tunes.
t Fig. 93. Qustered nuclei of a medullary cancer, described in the text Magnified about
400 times.
% Mu8. Coll. Surg. 252 ; and of St. Bartliolomew's, Series xxxv. No. 54.
640 UIDnLLART CANCBS — HICRO9COPI0 BTBSOIOII.
not only by its structure, but by its recurrence after ttmpntatjon, indbj
similar eecondarj disease of the inguinal glands. I foand scarcely iny
cells but such as are drawn. Some were narrow, tongne-shsped, brad,
and rounded or truncated at one end, and at the other elongated ind
tapering. Some were elongated at both ends; some oat-shaped; gone
very slender, with long awn-fihaped or cloven procesBea. All these htd
large, oval, well-defined clear nuclei, like those of ordinary cancer-cells,
and with distinct nucleoli. Their texture, also, appeared to resemble
that of common cancer-tfells ; they differed only in shape, being, in this,
most like the cells of recurring fibroid tumors (p. 412).
(/) In the two instances, I bave found cancers which, by th^
characters and history, should be called firm medullary cancer, and wbick
were, in great part, composed of much smaller, narrower, and proptn^
tionally more elongated cells than those last described. One of tbwe
was a large deep-seated tumor behind the inner ankle and in the sole o(
the foot, enclosing the posterior tibial and plantar vessels and nerve, and
the flexor tendons. In the other case, the primary tumor involved the
gum and larger part of the front of the lower jaw ; and similar secondary
disease was diffused through part of the right lobe of the thyroid gland,
and, in small masses, in both lungs. All the tumors were very firm and
elastic ; the fluid that they yielded was not creamy, but viscid and yel-
lowish. The tumor on the foot was gray, shining, minutely lobed, inter-
sected with opaque-whitc fibrous hands, and in its own tissue appeared
fibrous. That on the jaw was grayish-white, suffused with pink, glisten-
ing, but with no appearance of fibrous or other texture. In all there
were much molecular matter and granular debris, cancer-naclei, and ■
few cells of ordinary form ; but their essential structures were (as b
fig. 95) very small, narrow, and elongated cells and nuclei. The celb
were of various shapes ; some sharply caudate, some swollen in the middle,
some abruptly truncated. They looked wrinkled and pellucid. They
measured, generally, about j^^g of an inch in length. Some had elon-
* Fig. 04. Caudate ond vsriouil]' elongated cells or a iirm medullary cancer, dcKribedip
the teii. MaitniSed 430 limeB.
t Fig. 9(}. Small elongaterl cells am) nuclei, with n nuclei of odlinary ihape, from ■ fim
jneilullary tumot, as deaciibed alnye. MoKoiSed 3'JO timn.
MBDITLLABT CANOEB — MICB08C0PI0 BTBUCTUBB. 541
ited clear nuclei ; in others no nuclei appeared. Many free nuclei had
le same shapes as these cells, and of many corpuscles it was hard to
J whether they should be called cells or nuclei.
{jf) Sometimes one meets with cells, in medullary cancers, in which
iidei are not at first discernible. They are round, large, nebulous ; they
mtain many minute granules ; and, when water is added, it diffuses
leir contents, and may display a round nucleus, smaller, and more nebu-
\VB or granular than those of the typical cancer-cells.
(A) Cells containing many nuclei are regarded by some as frequent in
BTtain medullary cancers. I believe that such cells may occur, and that
ocasionally endogenous cells may be found within those of larger size
ad probably older growth; buti am more sure that cells containing
ells, or containing more than three nuclei, are very rare. What have
een described as brood-cells in medullary cancers, or as cells which, by
be multiplication of their nuclei, were effecting rapid increase of the
ancer, were, I believe, in some instances, the many-nucleated cells of
lyeloid tumors, and, in more instances, detached masses or fragments of
lolecular basis-substance in which nuclei were imbedded. I may add,
iiat I have not found in medullary cancers, any structures similar to
lose of the laminated cysts or capsules which occur in epithelial cancers.
Such are the chief varieties of the corpuscles of medullary cancer :
base, at least, are what I have found them presenting in their natural
bate. Much might be said respecting the changes effected in them by
be fatty and other degenerations and diseases, and about the confusion
rought into the microscopic diagnosis by the granular masses, free
nmular matter, and various debris hence derived. But for these I must
rfer to the general account of degenerations in previous lectures. "*" It
emains that I should speak of the substance with which the cells are
Hociated — the basis, intercellular substance, or stroma.
I need not repeat what has been said (p. 501) respecting the ^^ stroma,"
o-called, of a cancerous infiltration, — that it is only the tissue of the
rgan in which the cancer is seated. What I have now to describe is the
abfitance which is proper to the cancer, and in which the cancer-corpus-
les are suspended or imbedded.
(a) The cells and nuclei of medullary cancers may be suspended in
iqnid alone ; and the two, like a collection of fluid rather than like a
nmor, may be infiltrated in tissues, or, more rarely, may be contained
ti small cavities. This is not unfrequently the case in very rapid pro-
ioctions of cancerous matter, especially in secondary deposits. The
iquid (cancer-serum, as it has been named) is turbid ; it dims transmitted
ight, and has a finely molecular appearance. With the cancer-corpuscles,
Ad usually with granular matter, it makes the '^ cancer-juice ;" the pecu-
* Or, with more adirantage, to Lebert*s admirable account of the changes of the cancer-
dli, in his *< Traits pretiqae/' p. 23.
542 MBDULLART OANGEB — HICBOSOOPIO STBVOTUBB.
liar thick, creamy liquid, tinted with yellow, gray, pink, or purple, and
easily diffusible in water. The quantity of corpuscles in proportion to tko
liquid is various ; it may be so small, and the corpuscles themselves may be
so lowly developed, that the liquid, like a mere blastema^ may appetr
the chief constituent of the cancer.
{b) The same kind of liquid which, in the cases just referred to, fonos
the only material suspending the corpuscles, exists, also, in the solid me-
dullary cancers : it is the liquid of the '^ cancer-juice." But in the more
solid growths it appears to be diffused through some solid tissue, or in
the interspaces of a kind of spongy texture. This, which may be more
properly called a stroma of medullary cancer, is, in its simplest form, a
nearly pellucid substance, having either no trace of structure, or onlj
imbedded roundish or elongated nuclei ; but sometimes it appears fibrQ-
lated.
(c) Sometimes a framework, enclosing and supporting cancer-oelh,
appears to be formed by elongated fibro-cells arranged in series of
communicating lines. But, more commonly, a framework is constructed
of delicate pellucid or nucleated membrane, with filamentous tissue. In
the last case one obtains from a medullary cancer, after expressing ai
much as possible of its ^' juice," a kind of sponge, fiocculent and shreddji
constructed of membrane and filamentous tissue, with bloodvessels and
still-adhering cancer-particles. One thus sees that^ in even the minuter
parts, the substance of the growth is intersected with such partitions u
are visible with the naked eye, separating its larger lobes.
(d) Lastly, when medullary cancer is formed in bone or periosteum,
these tissues may, as I have said, grow excessively, and make for it a
fibrous or osseous skeleton (p. 535). Or, in other cases, new fibrous or
osseous tissue may be formed in the cancer, apparently by the develop-
ment of its own blastema, and may be as a stroma for the cancer-celb.
Medullary cancers thus composed are the chief examples of transition-
forms to the scirrhous cancers, on the one hand ; and, on the other, to
the osteoid cancers, in which the cancer-cells are wholly or nearly supe^
seded by the imperfect ossification of the cancerous blastema.
Rokitansky has lately published an essay* on the development of the
stroma or skeleton of cancers, an abstract of which, with copies of some
of his illustrations, may find here an appropriate place. It relates^
almost entirely, to that kind of stroma, in medullary cancers, which ie
described above (cj p. 541).
In certain examples of such a stroma or skeleton, two interlacing net-
works, or meshed structures, may be seen (figs. 96, 97.) One of these
(b) consists of slender bands, beams, or tubes (fig. 96, c) of an hyaline
substance, which contains oblong nuclei, and may be in part fibrillated
or transformed into filamentous tissue. The other and younger stmo-
* Ucber die Cntwickolung der ErebsgerOste, 1852, from the Sitzungsberichte der kail.
Akademie.
IlBDDLLARr OAHCBB — MICKOSCOPIO BTBUOtCKB. 543
tm (a) is oompoeed of larger op&qne bande or beuns, which are made
^ of nndeated cells, with elementaty graniilee, and variouB];^ P^T"
ibratod. These form a f«.««.*
network interlacing with
that formed by the hyaline
structures. Moreover, with
these opaqne beams, form-
ad <rf the same stmctores,
and projecting from them,
or firom the hyaline Btmc-
tana, there are hollow
laakflhaped or villous pro-
MBsea or outgrowths (fig.
97). Many of these pass
Uirongh the apertureB or
meabee in the networks,
jvojecting through them
with free ends; and the
^tertnreB with which many
of them are perforated, en-
larging by absorption, give
titem the appearance of
netted boUow bands or
eards. Some of these
■ame proeesBeB, also, ap-
pear pellmnd, hyaline, and
nucleated at their bases or
pedicles of attachment, or
through more or less of
ibeir length.
These several conditiooa
of the stroma indicate, Bo-
kitansky says, that it is con-
etmcted on that plan of
** deadritio vegetation, of
which the type and beat example is in the villous cancers. The growth of
the stroma takes place, at first, in the form of hollow, flask-shaped, budding
and branching processes or excrescences, which are composed of hyaline
membrane, and filled with nucleated cells and granules. These processes
cooataatly increase, throwing out fresh off-shoots of the same shape as
thanselvee first had (companAly with the increase of the exogenous villi
of the eptic chorion, described at p. 356). At the same time the cells,
or part of the cells, within the processes unite or fuse their cell-waUs,
while their nuclei remain and are elongated. Thus the texture of the
* Ri*. 90 and 97. DeTelopmenl of cancer-ttronia, dcKribed in die text. Magaifled 90
timw. From B<AitBiukr.
544 HEDULLABT CANCER OF THB TB8TI0LB.
growing stroma becomes hyaline, nucleated, or at last filamentous, ud
tabular ; and, as apertures are formed in it bj partial absorption of itB
textures, it becomes also meshed and reticulate or sponge-like. Fredi
dendritic vegetations arising, on the same plan, from the network thai
formed, pass with interlacements through its meshes ; and, by repetition
of the changes just described, increase the stroma and the complexity of
its construction.
The production of cancerous elements is commensurate with the growth
of the stroma, and they fill all the interstices, as well as, in some caaefl,
the tubules of the networks.*
The foregoing descriptions, though illustrated by only a few ezamplefl^
might suffice, I believe, for the medullary cancers of nearly all partSi
Yet it may be useful, if, after the example of the other lectures, I describe
some of the peculiarities which this form of cancer presents in certun
organs, — making a selection on the same grounds as in the last lectme
(p. 603).
In the Testicle, the medullary cancer is, usually, of the softer kind:
the firmer kind is not uncommon ; but examples of the scirrhous, or any
other form of cancer, except the medullary, are of exceeding rarity.
The medullary cancer commonly appears as a regular oval, or pyri-
form mass, which the toughness of the enclosing fibrous coat of the testi-
cle permits to grow to a great size without protrusion. As the fibrous
texture is distended by the growth, so it commonly also increases in
thickness. The surfaces of the tunica vaginalis are generally partially
adherent ; and what remains of the cavity, usually at its upper part, is
filled with serous or blood-tinged fluid. Part, or the whole, of the glan-
dular tissue of the testicle may, I think, be always found outspread on
* Rokitansky holds that the same method of construction is to be tmced in the ibcmatioii
of the layers of false membrane, which are found with reticulate or areolar surftces, or, later,
with interlacing iaminsB of fibres, on the pleura and other serous membranes. He illostntes
it, also, by the reticulate deposits on the interior of arteries; and lastly, by the examples of
cavernous or erectile tumors, t. e. not of such as he admits to be formed by dilatBtkm of blond*
vessels, but of such as are entirely new-formed structures. I have supposed these (see p. 486)
to be new growths, in which the bloodvessels greatly enlarging produce the character of in
erectile tissue. Rokitansky says that processes spring from the bands and the ccmls of the
cavernous tissue of such tumors, which processes end with flask-shaped swellings, and tre
eitlier opaque, and formed of nucleated cells, or are formed of nucleated hyaUne tissue, or
of long fibro-cells, or of fibro-cellular tissue. From these likenesses he deduces for the caver
nous tumors the same plan of development as for the stroma of cancer. He believes,
moreover, that the blood which some of them contain is formed in them ; saying that in
small, lately-formed, erectile tumors, no anastomosis between their blood-spaoes and die
bloodvessels in the parts around them can be found.
Lastly, he says (and the statements may be added to what is mentioned at p. 4S9) tbe
affinity of the cavernous blood-tumor witli cancer is more than a formal one. They not
unfrequently exist together in the same organ, e. g. in the liver ; and the stroma of the can-
cer may bo exactly like the mesh-work of the vascular tumor. CavemoDS tumors, also, muf
be found in large numbers at once in the most diflerent organs and tissues: for example
(as in a case related by him), in the whole peritoneum, the costal pleura, the subeutaneotts
tissue, one of the psoas muscles, the choroid plexuses, and the fat at the base of the heart
MEDULLABT OANCEB OF THB ETB. 645
Ae snrfaee of the tumor : the epididymis, often the seat of similar dis-
is generally flattened and expanded. Separate medullary cancers
J lie near; especially in the loose cellular tissue of the spermatic cord:
or, the growth may perforate the tunica albuginea, and extend exube-
rantly about the testicle in the sac of the tunica vaginalis, or in the loose
tiflsae of the scrotum : or, without communication, part of the cancer
fliay be within, and part around, the tunica albuginea.*
The general characters of the cancer-structure in the testicle are usu-
ally conformed to the type already described, yet these points may be
considered worthy of note : (1) Sometimes the lobes of the cancerous
HUBB are seyerally so invested with fibro-cellular tissue that they may
have the appearance of cysts filled with endogenous cancerous growths.f
(2) Portions, or whole lobes, of the tumor, degenerate and withered
into a yellow substance, like tuberculous or ^^ scrofulous" matter, are
usually seen ; especially near the central parts of the cancer. (8) Large
cavities full of blood may exist, and add to the difficulty of the diagnosis
from hsematocele. (4) The conjunction of medullary cancer with carti-
lage is more frequent in the testicle than in any other part (see p. 444).
(5) The disease very rarely affects both testicles, either at once or in
succession.
The medullary cancer of the Eye so rarely deviates from the general
duuracters of the disease, and, since Mr. Wardrop's first account of it,
has been described, in all works in Ophthalmic Surgery, so much more
folly than would here be reasonable, that I shall advert to only two
points which it illustrates. (1) It is especially apt to present, either in
parts or throughout, the melanotic form ; a fact which we can hardly
dissociate from that of its growth near a seat of natural black pigment,
and which illustrates the tendency, even of cancers, to conform them-
selves, in some degree, to the structures of adjacent healthy parts.
(2) It shows a remarkable disregard of tissue in its election (if it may be so
called) of a seat of growth. I fully agree with M. Lebert in his denial of
the opinion that either the retina, or any other tissue of the eyeball, is in
an or even in a large majority of cases the place of origin of the can-
eer. Rather, we have, here, a striking instance of what may be called
the oBoeatton of cancers : of their growth being determined to certain
places rather than to certain tissues. Any of the tissues within or about
the globe of the eye, or any two or more of them at a time, may be
the primary seat of the cancer ; and, probably, each of them is more
liable to be so than any similar tissue elsewhere is : the locality, there-
fore, which they all occupy, may be assumed as that to which the can-
• Mr. Preicott Hewen shoMred me a specimen in Mrhich healthy testicle was surrounded
hf meduUaiy cancer. Examples of similar cancers in the spermatic cord, the testicles lx>ing
healthy, are in the College Museum, No. 2462-3 : some affecting the undescended testicles
are xelated l^ Mr. Amott (Med.-Chir. Trans, xxz. p. 0).
t Mm. ColL Surg. Na 2390.
86
546 MEDULLABT CANCEB OF THB BEBA8T.
cerous growth is directed, rather than anj of the tissues themaelTes.
And so it appears to be, when, after extirpation, the ca&cer retiim8,aBif
with preference, in the same locality, although the whole of the first
growth, and of the tissues which it occupied, are removed.
The Breast is among the parts which are most rarely the seats of
medullary cancer. So rare, indeed, is well-marked medullary cancer of
the breast, in this country, that Mr. Lawrence, in his immense experi-
ence, has met with but two examples of it ; and, in our Museums, it is
very rarely seen. This rarity is the more remarkable by its contrast
with the occurrence of the disease abroad. In France, according to M.
Lebert,* about one-fifth of the cancers of the breast are ^'soft and
encephaloid." In America, Dr. J. B. S. Jackson has assured me that
the proportion is not less than one-fifth ; and I gather, from the records
of German writers, that it is with them about the same.
I have never seen, in the recent state, a medullary cancer of the breast
which had a brain-like or any other usual appearance if but I hate
observed four cases of what must be regarded as medullary cancer,
though widely deviating from the usual characters, and not resembled by
any of the same kind except some of those occurring in the brain. They
may be worth description, because they are with difficulty distinguished
from hard cancers, on the one hand, and from mammary glandular or
cystic tumors, on the other. If a general description may be drawn
from these few cases, it may be to the following effect.
The tumors are separable masses, closely connected with the surround-
ing mammary gland or fat, but not incorporated with them, and having,
in some instances, distinct thin capsules, — a character, at once distin-
guishing them from all the scirrhous cancers of the breast that I have yet
seen. They are, generally, seated on or near the surface of the gland,
" floating,'* as mammary glandular tumors often do. The skin over them
is upraised, thin and tense; not depressed, or morbidly adherent, or
itself cancerous ; but when ulceration is at hand, becoming livid, then
ulcerating sparingly, and then everted with the protruding and outgrowmg
tumor. The tumors are oval, flattened, rounded or nodular ; firm, some-
times very firm, but not hard or very heavy like scirrhous cancers, and
at or about their centres they feel like cysts tensely filled with fluid.
They may grow quickly, and to much larger size than scirrhous cancers ;
are not remarkably painful ; and appear prone to be associated with the
formation of large serous cysts. Their general history is that of ordi-
nary medullary cancers.
With these characters alone, the diagnosis of such medullary cancers of
the breast is very difficult ; all these equally belong to manmiary glandular
• Des Maladies Canccrciises, p. 326.
1 1 do not so consider two specimens in the Museum of St Bartholomew-y Series zzxt^
28, 29, removed from the front of the chest aAer amputation of the bieasts cm Bocoantof
extreme hypertrophy.
MEDULLABT OANOBR OF THE SUB0UTAKE0U8 TISSUE. 547
temors or proliferous mammary cysts. But the same disease may exist
in the axillary lymphatic glands, forming quickly-growing masses, apt to
le much larger than those in scirrhous cancer. And, if ulceration ensue
in the tumor, it becomes exuberant, with lobed and coarsely-granulated
firm growths, discharging offensive ichor, and sometimes profusely
Weeding.
When such tumors are removed, they are found, as already stated,
separable from the mammary gland ; it is pressed away by them, but is
iftBelf healthy. The section of the tumor is minutely lobed, with lobes or
^granulations" closely grouped, like those of a mammary glandular
tnmor. Their texture is close, more or less firm, easily crushed, shining
on the cut surface. In color, they are grayish, varied with dots and
irregular lines of yellow (which do not follow the course of the gland-
ducts), or, in parts, sufiused with Uvid or deeper purple tints. Parts of
them, or even whole lobes, may be soft, shreddy, pale yellow, like tuber-
culous infiltration ; and these seem to be portions that are degenerate and
withered, like the tuberculoid materials in other medullary cancers.
They yield, not a creamy fluid, but a turbid grayish, or viscid yellowish
one. In some instances large cysts lie in or upon them, filled with
serous, or blood-stained, or darker fluid.
In microscopic examination traces of a glandular acinous plan may be
•gain observed: the corpuscles of the tumor being, at least in parts,
grouped in round or oval forms, though the groups are not inclosed in
membrane. The corpuscles may be well-formed cancer-cells and nuclei
imbedded in molecular substance. But I have also found in them, with
these or alone, abundant nuclei (some free and some in cells), such as are
described at page 538, fig. 92. It was, chiefly, such nuclei as these
which being clustered, gave the minute appearance of glandular construc-
tion : and in some parts, these alone, clustered and close packed, seemed
to make up nearly the whole substance of the tumor.
In the Subcutaneous Tissue, or deeper areolar layer of the skin, the
medullary cancers, while generally conformed to the type, exhibit these
peculiarities: —
(1) They are apt to assume the melanotic state ; a fact allied to that
already mentioned of the cancers of the eyeball (p. 545).
(2) While, in nearly all other external parts, the medullary cancers
appear as single growths, they are hero very often multiple. Such
numerous cancers may grow after one affecting some distant organ ; or
may be first formed below the cutis. In the latter case, many may
appear coincidently ; oi^ when ii\ succession, none seem to be consequences
of the growth of their predecessors ; they all have the characters of
primary cancers, of '^cancers d'embl^e." In some cases all the tumors
appear in a single region of the body. In an old man, lately under Mr.
Lawrence's care, two medullary cancers were removed from the scalp,
I
I
548 MEDULLART CANCER OF THE LTMPHATIO GLAKDfi.
and four remained in it. In a case which I shall presently detail a large
number were seated on one arm and shoulder, but scarcely any appeared j
elsewhere. In some cases, on the other hand, they appear at abont the
same time, in many and distant parts ; and in some, though limited at
first to a single region, they grow successively in other parts more and more
widely distant. Such was the event in a remarkable case by Dr. Walahe.^
In this aptness to be the seat of many medullary tumors, the sabcn-
taneous tissue agrees most nearly with the serous membranes and tbe
liver and other glands. The separable tumors are generally isolabk,
oval, discoid, or lens-shaped : very rarely, I believe, they are pedmica-
lated : they do not commonly grow to a great size, or tend to ulceratioa
or protrusion, unless after injury. But there seems no limit to their
number ; it is as if the force of the disease, which, in other instanoea, is
spent in a single enormous growth, were here distributed among many.
(8) It is chiefly among these examples of multiple medullary cancen
that the occasional disappearance of a cancer, as if by a'bsorption, maj
be observed. The old man referred to, as under the care of Mr. Lawrence,
was admitted because one of the tumors on his scalp was largely and
foully ulcerated. The removal of it was deferred on account of the other
timiors, and especially on account of one behind the ear ; but in the
course of about a month this almost wholly disappeared. The largest of
those remaining was now removed ; and during the healing of the wound
the rest nearly disappeared, becoming gradually smaller and firmer. So,
in the case of multiple tumors of the arm, before the patient died, the
whole of the smaller tumors were completely removed during the slough-
ing and suppuration of the larger.
The Lymphatic Glands, so rarely the seat of primary scirrhous can-
cer, are often primarly afiected with medullary cancer. They are, indeed,
less frequently so afiected than they seem to be ; for, in some instances,
when the disease seems primary in them, it is only because of its pre
dominance over that in the organ with which they are connected. But,
in more instances than these the glands are first, and, for a time, ezcln-
sively afiected. The most frequent seats of such primary disease are the
cervical, inguinal, lumbar, axillary, and mediastinal glands : in a few
very rare instances nearly the whole lymphatic system has quickly be
come cancerous.
The primary cancer of the lymphatic glands usually affects, from the
first, more than one gland ; often, it extends through a whole group, and
so many tumors form in a cluster that one may doubt whether all of
them are in glands. They may present any of- the various forms of
medullary cancer ; and these peculiarities may be noticed in their course:
(1) They are rarely well marked in the first instance ; they appear like
* Medical Times and Gazette, Ang. 21 and 28, 1852. In hia Treatite on Ckncer, Dr.
Walshe gives a full analysis of all the cases previously poblisbed. See, mlao, the singular
case recorded by Mr. AnceW (^^ed.«Ch\c. Trans, xzv., p. 227.)
HEDULLABT CANCER OF THB RECTUM. 649
merely enlarged glands ; their constant and accelerating increase may
alone suggest the suspicion of the nature of the disease. (2) Cyst-for-
mation is frequent in connexion with them. Especially, I think, in the
neck, one may find serous cysts, in elderly persons, resting on clusters
of cancerous glands, and the cysts may be often evacuated, and will fill
again, while the main disease makes insidious progress deep in the neck.
(3) Partial suppurations may occur in the cancerous glands, rendering
the diagnosis for a time still more difficult. (4) It is especially among
the cases of cimcerous lymphatics that we may find those occurrences of
deep connexion, and of enclosing of large nerves and bloodvessels, to
which I have referred (p. 531). (5) Cancerous lymphatic glands often
give a fallacious support to the belief that innocent tumors are apt to
become cancerous; for the glands sometimes enlarge before the can-
eerous disease is established in them ; and since, in their simple enlarge-
iient, they are like simple tumors, there is an appearance of transmu-
tation, when in such a state they become the seats of cancer.
In the Bectum, and in other parts of the digestive canal, I have
already said that growths of medullary cancer may coexist with scirrhous
eancer. Whether in this combination or alone, the former disease may
i^ypear in at least three distinguishable forms. (1) It consists sometimes in
diffuse infiltration of creamy, white, or grayish cancerous substance in
the submucous tissue, the mucous membrane being, for a time, healthy,
bat raised into the canal with low unequal elevations. (2) Much more
oommonly, larger, and more tuberous circumscribed masses grow in the
submucous tissue, projecting and soon involving the mucous membrane,
then exuberant through ulcerated apertures in it, and often bleeding.
(8) With nearly equal frequency the disease has its primary seat in the
muoouB membrane. Here it forms broad, circular, or annidar growths,
of a soft, spongy, and shreddy substance. They are but little raised
above the level of the mucous membrane, unless it be at their margins,
wluch are usually elevated and overhanging, and when ulcerated sinuous
and everted. They are very vascular, justifying Rokitansky's expression
that the bloodvessels of the affected part of the membrane have assumed
the characters of those of an erectile tissue. They might produce little
Btricture of the canal, if it were not that they are, I think frequently,
associated with thickening and contraction of the tissues external to them.
It hardly needs to be added that in whichever part of the intestine
the disease commences it extends to the rest ; and from them to the sur-
rounding tissues ; exemplifying here as everywhere the coincident pro-
cesses of destruction and of more abundant formation. "*"
* When I have omitted all description of the medullary cancers of the utenis, hings, brain,
and many otlier organs in which they frequently occur, it will not, I hope, be forgotten that
my purpose is only to illustrate the general pathology of the disease by the best examples
which I have been able to study. To have entered further on the special pathology of can*
eer in eaoh organ would have been beyond my purpose, and quite superfluous while the
great works of Walshe and Lebert can be consulted.
550 MEDULLART CANOBE.
LECTURE XXXI.
MEDULLARY CANCER.
PART IL— PATHOLOGY.
TnE general history of medullary cancers presents the best marked
type of malignant growths. Among all tumors, they appear, in a general
view, the most independent of seat and of locality ; the most rapid in
growth ; the most reckless in the invasion of diverse tissues ; the most abun-
dant in multiplication : they have the most evident constitutional diatheais;
they are the most speedily fatal. All these facts will be illustrated bj
comparison of the following sketch with the corresponding histories of
the other forms of cancer.
(a) Among the conditions favoring the production of medullary caneer,
the peculiarities of the female sex, though not without influence, appear
far less powerful than they appear in the history of scirrhous cancen
The peculiar liability of the uterus so much surpasses that of any of tlie
male organs of generation, that women are certainly, on the whole, moK
liable than men are to this form of cancer. But when the medullary can-
cers of the generative organs of both sexes are left out, I cannot find,
either in my own tables or in those of Dr. Walshe and M. Lebert, that
either sex is notably more liable than the other to medullary cancer of
any part of the body.
(6) The medullary cancer is prone to occur at an earlier age than any
other form ; it is, indeed, almost the only cancerous disease that we meet
with before puberty. The three localities in which, according to M. Le-
bert,* cancer occurs at the lowest mean age are (in the order of their
liability), the eye, the testicle, and the osseous system. To these, while
confirming his observation, I would add the intermuscular spaces, and
other soft parts of the trunk and limbs. The mean age of the occur-
rence of cancer in these parts is under 40 ; in all other parts it is above
40, and in most of them above 60. Now the four localities named above
are those in which the medullary and melanotic cancers almost alone
occur as primary afiections.
From a tablef of 154 primary medullary cancers of the bones, soft
parts of the trunk and limbs, the eye and orbit, the testicle, breast, and
various other external parts, I find that the ages at which they occurred
were as follows : —
• Trait^ pratique, p. 140.
t The table is constructed from hearly equal numbers of M. Lebert's cases and my own;
and it may be worthy of remark, that in the case of every part the average ago is higher in
his cases than in mine.
I5FLQBX0B OV SEX AND AQE.
561
?1.
111
•2 .
1
Soft pi
tranl
til
1
9^
^
•
Before 10 years of age
_
2
M^
4
15
4
25
Between 10 and 20
— .
6
« ^"^
12
1
2
21
« 20 and 30
-~
3
3
11
4
12
33
« 30 and 40
2
3
2
6
2
17
32
" 40 and 50
2
6
2
11
1
8
30
« 50 and 60
3
2
3
4
5
3
20
AboTe 60 . . .
—
1
—
C
3
—
10
7
23
10
54
31
46
171
The striking contrast between this table and that of the 158 cases of
nrrhous cancer (p. 512) needs little comment. Of the scirrhous cancers,
not one occurred before the age of 20 ; of the medullary cancers, more
Sum a fourth began before that age : of the former nearly half com-
oenced their growth between 40 and 50 years of age; of the latter,
tttle more than a sixth : of the former, nearly three-fourths commenced
ifter 40 ; of the latter, little more than one-third did so.
The following table, also, may be compared with that at p. 513. It
hows, by similar calculations, the relative frequencies of medullary can-
len in external parts, in proportion to the number of persons living at
ttch of the successive decennial periods of life. The greatest frequency
B betweep 40 and 50, and, reckoning this as 100, the following numbers
nay represent the frequencies of the beginning of medullary cancers at
iher decennial periods : —
0 to 10 years
31
40 to 50 years
100
10 to 20 "
38
50 to 60 «
99
20to30 **
59
Above 60 «
44
30 to 40 *«
79
The chief points which this table may illustrate are (1), that the max-
nmm of frequency, in proportion to the number of persons living at the
ereral ages, occurs between 40 and 50, as well for the medullary as for
he scirrhous cancers of external parts; but (2) that there is a gradual
aoent to this maximum from the earliest period of life, and then a more
prmdual descent from it.
I believe, however, that, if we could reckon the frequencies of medul-
%Tj cancers of internal organs, we should find no such diminution after
he age of 50. Rather, it would appear that (in consequence, chiefly, of
he frequency of cancer of the stomach in advanced life) the frequency
f medullary cancers, in proportion to the number of persons living, con-
inues to increase up to the latest age. There are, I believe, no tables
1 which the medullary are separated from other cancers of internal
rgans ; but from those of the cancers of the uterus and stomach given by
lebert, and of the lungs by Walshe (of which, doubtless, the majority
rere medullary cancers), the proportionate frequencies at successive
552 HEDULLABT CANGBB.
periods appear to be as follows. (For comparison's sake, the proporti(m
between 40 and 50 years is still counted aa 100.)
0 to 10 years 0
10 to 20 ** (cancers of the lungs alone) . . 3
20 to 30 « 15-7
30 to 40 « 51
40 to 50 " 100
60 to 60 " 204
60 to 70 « 236
70 to 80 " (cancers of the stomach almost alone) 250
There are no data from which we could exactly reckon the relatiye
frequencies of medullary cancer in each part of the body, but there can,
I think, be little doubt that it is a disease which, on the whole, becomes
constantly more frequent, in proportion to the number of persons liTing
at each successive period of life, from the very earliest to the latest age.
(c) The influence of hereditary tendency is, probably, about the sane
in medullary as in scirrhous cancer. Among 82 patients, five were awan
of cancer having occurred in other members of their families, and of
these five, four reported that two members of their respective families
had died cancerous.
(d) Among 57 patients with medullary cancer; of external parts, IT
gave a clear history of previous injury or disease of the part affected;
in 7 the history was doubtful.
Certainly it would be impossible to prove, in many of these cases,
that the cancer was, in any sense, consequent on the injury after which
it formed ; and yet, while we find that a third of the patients with m^
dullary cancers ascribe them to injury or previous disease, while less than
a fifth of those with simple tumors, or with hard cancers, refer them to
such cause (p. 614), wc cannot fairly doubt that these local accidents
have influence in determining the place and time in which the medullary
cancerous disease shall manifest itself.
The influence of injury is very clearly shown in certain cases, in which
there is no appreciable interval between its immediate ordinary conse-
quences and the growth of a medullary cancer in the injured part. For
example, a healthy boy was accidentally wounded in his eye. It had
been perfectly sound to this time ; but, within a few days after the injury,
a medullary tumor grew from the eyeball. It was removed three weekfl
later ; but it quickly recurred, and destroyed life.
A boy fell and struck his knee. It had been perfectly healthy; but
the inflammatory swelling (as it was supposed) that followed the fall did
not subside : rather, it constantly increased ; and in a few weeks it be-
came probable that a large medullary tumor was growing round the lower
end of the femur. Amputation proved this to be the case.
Again, a sturdy man, at his work, slipped and strained, or perhaps
broke, his fibula. Three days afterwards he had increased pain in the
injured part, and at the end of the week swelling, which, though care*
INFLUENCE OF GENERAL HEALTH. 658
bDj treated, constantly increased. Eight weeks after the injury the
fwelling was found to be a large medullary growth around and within
the shaft of the fibula ; and the limb was amputated.
We musty I suppose, assume the previous existence of a cancerous
diathesis in the persons in whom these rare consequences of accidental
violence ensued: neyertheless, their cases prove, as I have said, the in*
floence of local injury in determining the time and place in which the
etnoer will be manifested ; and they may make us believe that, in many
eases, in which a clear interval elapses between the injury and the
^ipearance of the cancer, the effect of the violence, though less imme-
fiate, is certain.
(e) Although I know of no numerical evidence to support it, yet I
fliink the general impression must be true that medullary cancer is pecu-
fiarly liable to occur in those who have many of the features of the fair
gfcrumous constitution : in persons of fine complexion, light hair and eyes,
pale blood, quick pulse, and of generally delicate or feeble health.
Scirrhous cancer appears most frequent in those who have the opposite
duuracters of temperament. A difference also exists in relation to the
general health of those in whom the two forms of the disease are
severally observed. I mentioned (p. 515) that nearly three-fourths of
the Bubjects of hard cancer appear to have good general health at
and soon after its first appearance: the proportion of those in the
like condition with medullary cancer is not more than two-thirds ; the
remaining third have presented from the very beginning a loss of weight
and of muscular power,' accelerated action of the heart, quick breathhig
paleness, and general defect of health.
In the growth of medullary cancer we may chiefly observe these
three things — (1) their multiplicity in certain cases ; (2) their generally
rapid rate of increase ; (3) the occasional complete suspension of growth.
I have referred to their multiplicity in the subcutaneous tissue, but
again notice it, to mention the observation of Rokitansky,'*' that medul-
lary cancers.are sometimes developed in great number in the course and
among the phenomena of a very acute typhoid fever.
I do not know what their greatest rate of increase may be: but
it has in several cases exceeded a pound per month, and, except in the
instances of some of the cartilaginous tumors (p. 427, 428), it is, I believe,
unequalled by any other morbid growth. In general, the more rapid
the growth the less is the firmness, and the less perfect the development
of nuclei and cells, in the medullary tumor. Their rapid increase com-
monly indicates, not a special capacity of growth or multiplication of
cells in the tumor already formed, but an intense diathesis, an ample
provision of appropriate material in the blood. The growth is by simple
increase ; the materials once formed do not normally change their cha-
* Pathologlscho Anatomie, i. 373.
554 MBDULLART OANOSR.
racters ; there are no stages of crudity or maturity ; the disease is, in
its iisaal and normal course, from first to last the same.
But while these things justify the expression that the medullary is, on
the whole, the most acute form of cancer, yet there is, I believe, none in
which arrest or complete suspension of progress is so apt to occur.
These cases have occurred within my own observation. A man, 88 yean
old, had a slight enlargement of one testicle for 15 years, and its rate of
increase was often inappreciable. At the end of this time rapid growth
ensued. On removal, well-marked medullary and melanotic cancer was
found, and was the only apparent source of the enlargement. He died
soon after the operation with recurrence of the disease.
A man, 42 years old, had a large increasing medullary tumor of the
ilium. He had also a tumor in the upper arm, which had grown slowly
for seven years and had been stationary for three years. When he died,
the tumor in the arm had as well-marked characters of medullary cancer
as that of the ilium, or of any other of the several parts in which
similar disease was found.'*'
A man, 35 years old, had numerous medullary tumors in his ri^t
upper arm, shoulder, and axilla, all of which had commended their
growth within three months, and were very quickly increasing. One,
which appeared to be in every other respect of the same kind, had been
stationary for twelve years in the groin, and another nearly as long in
the neck.
Sir Astley Cooper removed a gentleman's testicle for what was
believed to be medullary cancer. He remained well for twelve years,
and then died with certain medullary cancer in the pelvis.
Dr. Baly had a patient who had observed for several years a tumor
connected with two of his ribs. It had scarcely enlarged, till shortly
before his death : then it quickly increased, and, at the same time,
numerous medullary cancers appeared about it and in more distant parts*!
Gases such as these occur, so far as I know, in no cancers but those
of the medullary and melanotic kinds. They seem to be quite inexpli-
cable ; and as yet no facts have been observed which would show a pecu-
liarity of structure in the arrested cancers corresponding with the
strangeness of their life.
As the medullary cancers grow, the parts about them generally yield,
and some among them grow at once in strength and in extent, and for a time
retard both the increase and the protrusion of the tumor. Because the
skin over a medullary cancer is not often infiltrated (as that over a
hard cancer usually is), we do not often see the kinds of ulcer described
in the last lecture (p. 517). Neither is there, in medullary cancers gene-
* Museum of St Bartholomew's, Series L Nos. 235 to 240. Case related by Mr. Stanley
in Mecl.-Chir. Trans., xxviii. p. 317.
t The tumor on the ribs is in the Museum of St. Bartholomew's. It appears an ordi-
nary medullary cancer, with a hard bony skeleton.
MEDULLART CAKCEB — ULCBRATIOK. 655
rally, any remarkable proneness to ulceration. The usnal course is,
that, as the tumor grows, the skin and other parts over it become thinner
ind more tense ; then, as the growth of the tumor is more rapid than
theirs, they inflame and ulcerate, and a hole is formed over the most
prominent part of the tumor. There is nothing specific or character-
iifeic in this ulceration ; it is only such as may ensue over any quickly
growing tumor ; but the continued rapid increase of the cancer makes it
protrude and grow exuberantly ; it throws out fungus, as the expression
is. The exuberant growth, exposed to the injuries of the external
world, inflames, and hence is prone to softening, bleeding, ulcerating,
ind sloughing.'*' These may keep down its mass ; yet it may grow to a
Tast size, having only its surface ulcerated; lower down, it usually
adheres to the borders of the apertures in the skin, and overhangs and
everts them. This is usually the case with the huge outgrowths of medul-
lary cancer that have protruded from the eyeball, after penetrating
through ulcers of the overstretched cornea or sclerotica. And similar
exuberant growths are often seen when medullary cancers have pene-
trated the walls of various cavities or canals : thus, e, ^., they grow along
the canak of veins when they have entered them by, it may be, a single
small orifice.
In the cases of difinse infiltration of an exposed superficial tissue {e. g.
xiS. the mucous membrane of the stomach or rectum), the cancer usually
ulcerates widely with the tissue it afiects, and herein imitates more nearly
the characters of the ulceration in scirrhous and epithelial cancers.
Through the constantly deepening cachexia, with which the increase
in the medullary cancers is usually commensurate, and which is augmented
by the various influences of the local disease, the usual course of the
medullary cancer is uniformly towards death ; and rapidly thither, even
when the growth does not involve parts necessary to life. And yet, as
Etoldtansky has observed,t there is no form of cancer in which sponta-
neous natural processes of healing so often occur. Doubtless nearly all
the reputed cases of the cure of cancer have been erroneously so re-
garded ; yet instances may be easily gathered of at least temporary cure ;
and these are important in relation to the general pathology of cancer,
unce they afibrd the best examples of the effects of its degenerations and
diseases.
The degenerations of medullary cancer are chiefly three : withering,
fatty, and calcareous degeneration. Its chief diseases are equal in num-
ber— ^hemorrhage or apoplexy, suppuration, and sloughing.
A medullary cancer may gradually decrease, becoming harder, as if by
shrivelling and condensing, and at length may completely disappear. I
•In Series xxxv. No. 00, in the Museum of St Bartholomew's, is a large medullary tumor
vliich bod grown in the subcutaneous ticsue of the back, and, aAer the skin over it had
Dicerated, was in one mass squeezed out through the opening, while die patient was en-
deavoring to raise herself in bed. f ^^^^ ^^^ P* ^^*^*
556 MBDULLABT CANCBB.
have mentioned such eases at p. 548 ; and I have seen the same happen
after partial removal of cancers.
A firm medullary tumor was seated deep in the substance of a yomig
woman's parotid gland. Its removal with the knife could not be safdy
completed ; about a fourth part of it was left behind, and the wound was
left to heal in the ordinary manner. It healed quickly, enclodng the
remains of the tumor ; but after some time all the appearance of swel-
ling subsided, and no renewed growth ensued till after a lapse of three
months, when it was renewed, but not more rapidly than before.
A woman's humerus was amputated with a large mass of firm medat
lary cancer surrounding its neck and the upper part of its shaft. The
same disease existed in all the muscles about this part of the bone; and
Ihe patient was so exhausted, that the dissection necessary for the re-
moval of the whole disease could not be completed. Large portions of
it were left in the deltoid and great pectoral muscles. In two month
after the operation, however, the wound had very nearly healed, and no
trace could be felt of the masses of the cancer in the muscles. Kor did
any perceptible recurrence take place till more than four months after
the operation. At that time renewed growths appeared at the scar, and
in the thyroid gland, and quickly increased.
To these cases I might add at least three in which I have known p(v-
tions of cancerous growths left in the orbit after incomplete operations;
in all of which complete healing ensued, and one, two, or three months
elapsed before any renewed growth was evident in the portion of the dis-
ease that was left. In all these cases the disappearance of the cancer
may have been due in part to the disease and rapid degeneration excited
in it by the injury of the operation and its consequences ; and in all, the
growth was renewed within three months of the disappearance ; a falla-
cious hope was in all excited, and bitterly disappointed. But I shall
have presently to refer to a case in which the removal of cancers was
independent of local injury.
It is most probable that fatty degeneration coincided with the wasting
and absorption of cancer which occurred in the preceding cases ; for it
seems to be the most frequent change when growth is hindered. I have
already referred to the fatty degeneration which, in medullary cancers,
as in other tumors, may give an appearance of buff" or ochre-yellow lines
or minute spots scattered, as a reticulum, through their substance. I
have also described (p. 527) the similar but larger degeneration which
ensues in those portions or lobes of medullary cancers, that are found as
tuberculoid masses (phymatoid, of Lebert), yellow and half dry, among
the other portions that appear actively progressive. In both cases it is
probable that the altered substances are incapable of further growth ; but
the change, being only partial, does not materially afiect the progress of
the whole mass. But, though more rarely, a whole mass (especially when
many exist, aa in the liver), may be found white, or yellowish-white, soft,
MEBULLABT CANCBR — DISBASBS. 557
putiall J dried, close-textured but friable, and greasy to the touch — ^in a
rtate of what Rokitanskj has called ^^ saponification." In such cases,
naaj of the cancer-cells and nuclei have the characters of the granular
IT fatty degeneration, and may appear collapsed and shrivelled ; and they
ire mingled with abundant molecular matter and oil particles of various
uses, and often with crystals of cholestearine or with coloring granules.
ML the analogies of such changes in other parts imply that cancers thua
legenerated must be incapable of increase ; they are amongst those which
Day well be called, as by Rokitansky, obsolete. But I am not yet sure
diat these gradual changes have been ever followed by absorption of the
iltered cancer-substance, and by healing :* the disease ceases but doea
BOt disappear : and usually, while one mass is thus changing, others are
pirogressive.
The calcareous degeneration is much more rare than the two preced-
ing. It is fully described by Dr. Bennettf and Rokitansky,| and is in
ill essential characters similar to that which so often occurs in degenera-
ting arteries, calcified inflammatory products, &;c. The earthy matter,
in minute granules, is commonly mingled with fatty matter, and, accord-
ing to the quantity of fluid, is like more or less liquid or dry and hardened
nortar: if hardened it lies in grains, or larger irregular concretions, in
the substance of the tumor. Its indications are the same as those of the
iMj degeneration with which it is usually mingled.§
Among the diseases of medullary cancers their proneness to bleeding
(Day be mentioned. Hence their occasionally abundant hemorrhagea
irhen protruding, and the frequent large extravasations of blood in them,
noiously altering their aspects as it passes through its stages of decolo-
risation, or other changes. The extreme examples of such bleeding can-
sen constitute the fungus haematodes.
Acute inflammation also is frequent, especially in such as are exposed
lirough ulcers. It may produce not only enlargement of the bloodvessels
ind swelling of the tumor, but softening, suppuration, and, I believe,.
ither of its ordinary effects. The softening may be compared with that
irhich occurs in inflammation of any natural part, like which, also, it is, I
believe, often attended with a rapid fatty degeneration or a disintegration
nf the cancer-structures. I am not disposed to think with Rokitansky
[p. 527), that the reticulum, or other ordinary yellow deposits in cancers,
lie due to inflammatory exudations passing into and propagating a fatty
* These supposed cases of healing of cancer of the liver, reported as having occurred at
Pkagoe, admit of other explanations. (See Lebert, Traits Pratique, p. 72.)
t On Cancerous and Oancroid Growths, p. 214. ^ ^^^' ^^^ P' ^^*
S I have little doubt that the melanotic cancer might be truly described as a pigmental
Icgeneration of the medullary cancer (except in the few instances in wliich epithelial can-
ytn are melanotic). But part of another lecture will be devoted to this. The same lecture
■iO oompiise the colloid or alveolar cancer ; and I shall have occasion to mention in it
die frequent occurrence of cysts in me<iullary cancers, some of which might perhaps be do-
mibed •■ a cystic diseiMe of the cancers.
558 MEDULLART OANOBR — TBXPOBABT OUBB.
transformation ; but I think that acute inflammation in & medulltfj or
any other cancer is likely to be attended with the same degenentiTe
Boftening and transformation, as we find constituting a part of the inflam-
matory process in the natural tissues. Thus degenerating, and whether
with or without suppuration, a medullary cancer may be oompletdj
removed.
By sloughing, also, a medullary cancer may be wholly ejected ; and
this event is more likely to happen than with any other kind of cancer,
because no other is common in the form of an isolable mass. I might
collect several cases in which it has occurred, but none is more remarkable
than this."*" A strong man, 46 years old, under Mr. Lawrence's care^
had a large firm medullary cancer deep-seated in his thigh, of about nine
months' growth, painful and increasing. In an attempt to remove it, the
femoral artery was foimd passing right through it ; its connexions, also,
appeared so wide and firm, and bleeding ensued from vessels of so great
size, that the operation was discontinued after about half the surface of
the tumor had been uncovered. The tumor sloughed, and gradually wu
completely separated. It came away with nearly three inches of the
femoral artery and vein that ran through it. No bleeding occurred
during or after the separation, and the cavity that remained in the thigh
completely healed. The man regained an apparently good health for a
few weeks; then the disease returning in the thigh, proved quickly
fatal.
In the following strange case nearly all the methods of spontaneous
temporary cure which I have been illustrating were exemplified.
A tall, healthy-looking man, 36 years old, came under my care in July,
1850. In October, 1849, he thought he strained his shoulder in some
exertion, and soon after this he noticed a swelling over his right deltoid
muscle. It increased slowly and without pain for nine months, and wm
thought to be a fatty tumor, or perhaps a chronic abscess. About the
beginning of July, other tumors appeared about the shoulder ; and, when
I first saw him, there was not only the tumor first formed, which now
covered two-thirds of the deltoid, but around its borders were numerous
smaller round and oval masses ; in the axilla was a mass as large as an
egg ; over the brachial vessels lay a series of five smaller tumors, and a
similar series of larger tumors over the axillary vessels reaching under
the clavicle. A small tumor of several years' date lay at the border of
the sterno-mastoid muscle ; and one, which had been noticed for twelve
years, was in the right groin. All these tumors were soft, pliant, painless,
subcutaneous, movable, more or less lobed. There could be very little doubt
that they were medullary cancers, and their complete removal seemed
impossible ; but it was advised that, for proofs sake, one should be excised.
I therefore removed one of those near the chief mass. It was composed
of a soft grayish substance, with a pale purple tinge, lobed, easily reduced to
* The case is fully reported by Mr. Abertietby Kingdon, in the Medical Gazette, 1850.
MBDULLABT CANOEB — TEMPOBART CUBE. 659
palp, and in microscopic structure consisted almost wholly of nucleated
eells exactly conformed to the very type of cancer-cells. The operation
was followed by no discomfort ; and, in a few days after it, the patient
left the hospital, still looking healthy, but, I supposed, doomed to a
rapidly fatal progress of the disease.
At home, near Dover, he was under the care of Mr. Sankey. In a few
days after his return, the skin over the largest tumor cracked, and a thin
discharge issued from it. Four days later he was attacked with sickness,
diarrhoea, and abdominal pain, and in his writhings he hurt his arm.
Next day, three or four more openings had formed over the great tumor,
and the scar of the operation-wound reopened: the tumor itself had
rapidly enlarged. From all these apertures pus was freely discharged,
and in a day or two large sloughs were discharged or drawn through
them. With the sloughing, profuse hemorrhage several times occurred.
All the upper part of the arm and shoulder was undermined by the
doughing, and a great cavity remained, from which, for three weeks, a
thin foetid fluid was discharged, but which then began to heal, and in
twelve weeks was completely closed in.
While these changes were going on in the tumors over the deltoid and
in those near it, that in the axilla was constantly enlarging. It became
^* as large as a hat,*' and early in September it burst ; and through a
small aperture about six pints of pus were rapidly discharged. A great
cavity, like that of a collapsed abscess, remained ; but it quickly ceased
to discharge and healed. In the same time all the tumors over the
brachial vessels disappeared ; they did not inflame or seem to change their
texture ; only, they gradually decreased and cleared away, and with them
that also disappeared which had been in the groin for twelve years.
It need hardly be said that during all this time of sloughing and sup-
puration the patient had been well managed, and amply supported with
food and wine and medicine. About the end of October he appeared
completely recovered, and returned to his work. I saw him again in
January, 1851. He looked and felt well, and, but that his arm was weak,
he was fully capable of work as an agricultural laborer. Over the lower
half of the deltoid there was a large irregular scar ; and this appeared
continuous posteriorly with a small mass of hard tough substance, of
which one could not say whether it were tissues indurated after the
sloughing, or the remains of the tumor shrivelled and hardened : whatever
it was, it was painless and gradually decreasing. No trace remained of
the other tumors in the arm, except a small mass like a lymphatic gland
in the middle of the upper arm. In the axilla there was a small swelling
like a cluster of natural lymphatic glands. The tumor also remained at
the border of the stemo-mastoid muscle, and was rather larger than in
July.
In February, 1851, the swelling in the axilla began to increase ; its
growth became more and more rapid. By the end of March the arm
was greatly swollen ; he suffered severe pain in and about it ; his health
560 MEDULLART CANCER — PAIH AND CACHEXIA.
failed ; he had dyspnoea and frequent vomiting, and died with pleiiro>
pneumonia on the 20th of April. The tumor in the axilla (the only one
found after death) was about eight inches long, oval, lobed, soft, Tascnlar,
and brain-like, and consisted, chiefly, of small apparently imperfectlj
formed cancer-cells.
Such a case as this needs little comment. It illustrates the spontaneous
removal, and, so far, the healing, of medullary cancers by absorption, by
inflammation, and abundant suppuration, and by sloughing. It shows the
absorption of the cancerous matter, doubtless in an altered state, accom-
plished without evident injury to the economy. And it illustrates the
cancerous diathesis quickly re-established after being, we must suppose,
suspended or superseded, for a time, during the removal of its products.
Hard, therefore, as, we may say, the struggle for recovery was, it wm
not successful.
It is scarcely possible to give general illustrations of the pain and
other phenomena attendant on the progress of medullary cancer ; for
these are variously modified by the many organs in which it may hm
its primary seat. The history of some of the medullary cancers, whidi
grow as distinct tumors, may teach us that the pain is not an affection
of the cancer itself, but of the organ which it occupies. Such cancerous
tumors, in the subcutaneous cellular tissue, are, I believe, rarely the
sources of pain; often they are completely insensible: yet the sane
kind of tumors seated among the deeper parts of limbs, or enclosed in
the testicle, or in bone, seem to be usually painful, and often severely so.
The difference indicates that the varying pain is not of the cancer, but of
the part it fills.
The cachexia is, in the later periods of the disease, too much varied
by the disturbed functions of the organs specially affected to admit of
general description. But it is chiefly in this form of cancer that, early in
the disease, and even while the local affectign seems trivial, and involves
no important part, we often find the signs of the general health being
profoundly affected ; the weight and muscular power regularly diminish^
ing, the complexion gradually fading, the features becoming sharper, the
pulse and breathing quicker, the blood more pale. Such events are,
indeed, inconstant, both in the time of the occurrence and in thdr
intensity ; but in many cases they are far too striking to be overlooked;
the defective nutrition of the early stages of phthisis is not more marked:
the evidence is complete for the proof of a distinct cancerous cachexia,
which is indeed commonly indicated and may be measured by a can-
cerous growth, but which may exist in a degree, with which neither the
bulk, nor the rate of increase, of the growth is at all commensurate.
To estimate the general duration of life in those who have medullary
cancers, those cases alone should be reckoned in which parts whose
functions are essential to life are affected ; — such as the bones and soft
parts about the trunk and limbs, the testicle, the eye, and other external
organs. From a ta\Ae of 50 c.«a^ of medullary cancers in these parts
DURATION OF LIFE. 661
(mdading eight cases of cancer of the bones by M. Lebert), in all of
which the disease pursued its course without operative interference, I
find the average duration of life to be rather more than two years from
Ihe patient's first observation of the disease.'*'
Among 45 of these patients, —
6 died within 6 months
7 « between 6 and 12 *^
11 « « 12 and 3 8 "
4 « ** 18 and 24 «
7 « ** 24 and 36 •«
7 « « 36 and 48 «
3 " more than 48 months from the commencement of the disease.
A oompajrison of this table with that at p. 524 will show, in striking
contrast with the history of scirrhous cancer, the rapidity of this form in
running its fatal career ; a rapidity which is certainly not to be ascribed
to the earlier exhaustion produced by hemorrhage, discharge, pain, or
other local accidents of the disease, but is mainly due to the augmenting
cachexia. The same comparison will show how small is the proportion of
those in whom the disease lasts more than four years ; and there seem to be
no cases parallel with those of scirrhous cancer which are slowly progressive
through periods of five, ten, or more years. I have mentioned instances
of the apparent suspension of the disease ; but these are different from
the cases of constant slow progress, the rarity of which supplies an
important fact in diagnosis, in the great probability that a tumor is not
a medullary cancer, if it have been increasing for more than three years
without distinct manifestation of its cancerous nature.
The effect of removing medullary cancers is, on the whole, an increased
average duration of life ; but chiefly, I believe, because in a few cases
the operation is long survived, and in some, death, which would have
speedily ensued, is for a time arrested. In the majority of cases the
operation, if its own effects be recovered from, seems not to affect the
average duration of life. Thus in 46 cases in which external medullary
cancers were removed by excision, or amputation of the affected part, the
average duration of life was something more than 28 months. Among
51 cases (including 9 cases of extirpated cancer of the eye, from M.
Lebert) these were the several times of death, reckoning, as before, from
the first observation of the disease by the patient : —
Within 6 months 1
Between 6 and 12 '* 13
« 12 and 18 « 7
« 18 and 24 " 8
•* 24and36 « 11
« 36 and 48 « 3
Above 48 « 8
* I have not reckoned in this table the exceptional cases referred to at p. 554, in which
the disease appears to be suspended for some years. But I have included five cases in which
tba patients were still living beyond the average time. In the 45 already dead, the average
duration of life was 23*8 months.
86
562 MSDULLART OAKOEB.
The comparison of this table with that at top of page 561 will show th&t
the only notable contrast between them is in their first and last lines.
If the operation be recovered from, the regular course of events brings
about the renewal of cancerous growth, either near the seat oi the former
growth, or in the lymphatics connected therewith, or, more rarely, in
some distant part. In 38 cases of medullary cancer, affecting primarilj
the same external organs as afforded the cases for the former tables, I
find the average period of recurrence after the operation to have been
seven months. I have reckoned only those cases in which a period of
apparent recovery was noted after the operation ; all those cases are
omitted in which the disease was not wholly removed, or in which it is
most probable that the same disease existed unobserved in lymphatics or
other internal organs at the time of operation. Yet the average rate of
recurrence is fearfully rapid.
It was observed in betweenr—
1 and 3 months in IS cases
Sand 6 " 11 "
6 and 12 « 4 «
12 and 24 " 3 «
24 and 36 « 2 «
Among the 51 cases in the table at the foot of page 561, those of five
patients are included, who are living, without apparent return of diseMC,
for periods of 3, 3 J, 4 J, 5, and 6 years after operation ; and I have re-
ferred already to one case in which a patient died with cancer in the pelvis
twelve years after the removal of a testicle which was considered cancer-
ous. Of cases more near to recovery than these I can find no instances
on authentic record.
The cases I have been able to collect supply little that is conclusiTe
respecting the different durations of life, according to the age of the
patient, the seat of the cancer, and other such circumstances. In chil-
dren under ten years old, the average duration of life, with medullary
cancers of external parts, is, I believe, not more than eighteen months;
after ten years, age seems to have little or no influence. According to
the part affected the average duration of life appears to be greater in
the following order : — the testicle, the eye, the bones, the soft parts of
the limbs and trunk, the lymphatics ; but the difference is not consider-
able. The average for the cancers of the testicle is about 23 months;
that for the tumors in the limbs and trunk nearly 30 months. It is the
same, I believe, with the results of operations ; recurrence and death
occur, on the whole, more tardily after amputations for medullary cancers
of the bones and soft parts of the limbs, than after extirpations of the
eye or testicle ; but there are many obvious reasons why we cannot hence
deduce more than a very unstable rule for practice. The previous dura-
tion of the disease seems, also, to have little influence on the time of
recurrence after the operation : the only general rule seems to be, that
DUBATIOK OF LIVE. 568
the rapidity of recurrence correspondfi with that of the progress of the
primary disease.
Now, respecting the propriety of removing a medullary cancer in any
ungle case, much that was said respecting the operation for scirrhous cancer
of the breast might be repeated here. The hope of finally curing
the disease by operation should not be entertained. Such an event may
liappen, but the chance of it is not greater than that of the disease being
spontaneously cured or arrested ; and the chance of any of these things
is too slight to be weighed in the decision on any single case. The
question, in each case, is whether life may be so prolonged, or its sufferings
80 diminished, as to justify the risk of the operation. In general I think
the answer must be afiBrmative wherever the disease can be wholly re-
moTed, and the cachexia is not so manifest as to make it most probable
that the operation will of itself prove fatal.
(1) The number of cases in which the patients survive the operation
for a longer time than that in which, on the average, the disease runs
its course, is sufficient to justify the hope of considerable advantage from
the removal of the disease. On the other hand, the number of chronic
cases of medullary cancer is so small, that no corresponding hope of a
life being prolonged much beyond the average can be reasonably held, if
the disease be left to run its own career.'*'
(2) The hope that the removal of the cancer will secure a considerable
addition (two or more years, for example) to the length of life, will be
more often disappointed than fulfilled. But, even when we do not enter-
tain this hope, the operation may be justified by the belief that it will
avert or postpone great suffering.. The miseries attendant on the regu-
lar progress of a medullary cancer, in any external part, arc hardly less
than those of hard cancer of the breast ; they are such, and in general
so much greater than those of the recurrent disease, that, unless it is very
probable that the operation will materially shorten life, its performance is
warranted by the probability of its rendering the rest of life less burdensome.
(8) A motive for operation in cases of supposed medullary cancers
may often be drawn from the uncertainty of the diagnosis. This is espe-
daUy the case with those of the large bones, for the removal of which
the peril of the necessary operation might seem too great for the pro-
babOity of advantage to be derived from it. I have referred to cases of
cartilaginous and myeloid tumors of bone (pp. 427, 448, 450) in which
during life the diagnosis from medullary cancers was, I believe, impos-
sible. In all such cases, and I aba sure they are not very rare, the
observance of a rule against the removal of tumors or of bones believed
to be cancerous, would lead to a lamentable loss of life. All doubts
respecting diagnosis are here to be reckoned in favor of operations.
* The difference here stated may seem opposed by the tables in the foregoing pages. I
must therefore state that, at page 554, 1 have referred to all the cases of chronic or suspended
meduUaiy cancer that I have ever seen or heard of; but that the cases of operations sur-
vived fiir more than three, years mentioned at the foot of page 5C1, were not selected on this
acooimt, but occurred in the ordinary course of observation.
1
564 EPITHELIAL OAHCSB. i
LECTURE XXXIL
EPITHELIAL CANCER.
PART I.— ANATOMY.
Epithelial cancer has its primary seat, with very rare excepti(HU,
in or just beneath some portion of skin or mucous membrane. Its most
frequent locality is the lower lip, at or near the junction of the skin and
mucous membrane ; next in order of frequency it is found in the prepuce^
scrotum (of chimney-sweeps), labia, nymphae, and tongue: more rareljit
occurs in very many parts, — as at the anus, in the interior of theched[,
and upper lip, the mucous membrane of the palate, the lamyz, pharynx, ud
cardia, the neck and orifice of the uterus, the rectum and urinary bladder,
the skin of the perineum, of the extremities, the face, head, and Tariooi
parts of the trunk. In the rare instances of its occurrence, as a primaij
disease, in other than integumental parts, it has been found in the inguiul
lymphatic glands (in a case which I shall relate), in bones,'*' and in the
tissues forming the bases or walls of old ulcers.f
By extension from any of its primary seats, an epithelial cancer may
occupy any tissue : thus, in its progress from the lip, tongue, or any other
part, muscles, bones, fibrous tissues, are alike invaded and destroyed by
it. As a secondary disease, or in its recurrence after removal by opera-
tion, it may also have its scat in any of these tissues at or near its pri-
mary seat ; but it more commonly afiects the lymphatic glands that ut
in anatomical connexion therewith ; and, very rarely, it has been found
in internal organs, the lungs, liver, and heart.J
The essential anatomical character of the epithelial cancer is, that it
is chiefly composed of cells which bear a general resemblance to those
of such tessellated or scaly epithelium as lines the interior of the lips and
mouth,§ and that part of these cells are inserted or infiltrated in the
interstices of the proper structures of the skin or other afiected ti8Siie.||
* Virchow, in the WOrzburg Verhandlungen, i. 106.
t The primary seats of cancer, in the coses from complete records of which the fbllowiiv
descriptions are drawn, were as follows: — Lower lip, 9 cases : tongue, 9; Bcrotum, 6; hot
3 J penis, 3; labia, 2; gum, 2 ; integuments of the trunk, 2; of the upper extremity, 3;
lower extremity, 2 j ear, eyelids, interior of the cheek, neck, perineum, arms, larynx, inguinal
lymphatic glands, each 1. With very few exceptions, these are cases in which the disease
was removed by operation or examined ai\er death : in all such cases the microscopic chaite-
ters of the structure were observed. I may add that the account drawn chiefly from these
cases is confirmed by the recollection of a much larger number which I have observed bot
have not recorded.
i In the lungs and in the heart, in the Museum of St Bartholomew's. In the liver oooe,
by Rokitansky (Pathol. Anat. i. 386). In the lungs and in the liver, in the Museums of
Berlin and WQrzburg (Virchow, I.e.; and in his Archiv, B. iii. p. 222).
§ In very rare cases the cells, or part of them, are like those of columnar epithelium
(see pp. 582, 587).
I In assigning these two coTid\tiou« «a the essential characters of epithelial
VABIBTIBS — EXTERNAL CHARACTERS. 566
The epithelial cancers of the skin or mucous membrane from which,
II types, the general characters of the disease must be drawn, present
many varieties of external shape and relations, which are dependent,
diiefly, on the situation in which the cancerous structures are placed.
They may be either almost uniformly diffused among all the tissues of the
ddn or mucous membrane, predominating in only a small degree in the
papillae; or the papillae may be their chief seat; or they may occupy
only the sub-integumental tissues. As a general rule, in the first of
these cases, the cancer is but little elevated above or imbedded below the
normal level of the integument, and its depth or thickness is much less
than its other dimensions ; in the second, it forms a prominent warty or
exaberant outgrowth; in the third, a deeper-seated flat or rounded mass.
These variettes are commonly well marked in the first notice of the cancers,
or during the earlier stages of their growth ; later they are less marked,
because (especially after ulceration has commenced) an epithelial cancer,
which has been superficial or exuberant, is prone to extend into deep-
seated parts; or one which was at first deeply seated may grow out exube-
rantly. Moreover, when ulceration is in progress, a greater uniformity
of external appearance is found ; for, in general, while all that was super-
ficial or exuberant is in process of destruction, the base of the cancer is
constantly extending both widely and deeply into the subintegumental
tissues.
I believe that it will be useful to describe separately the external cha-
racters of the two principal varieties of epithelial cancer of the integu-
ments here indicated ; and (while remembering that mingled, transitional,
and intermediate specimens may be very often seen), to speak of them
as the superficial or outgrowing, and the deep-seated, forms of the
disease.'^
Among the examples of the superficial epithelial cancers, the greater
nunely, both the construction with epithelial cells and the insertion of such cells among the
original, though often morbid, textures of the alfected part, I make a group of diseases less
comprehensive than citlier the " Cancroid" of Lebcrt and Bennett, or the " Epithelioma" of
Hunover. These excellent pathologists, and many others following them, would abolish
■Itogetlier the name of epithelial cancer, and place the cases which are here so designated
in a groap completely separate from cancers, as exemplified by the scirrhous and medul-
buy fcrms. It is not without much consideration that I have decided to, differ from such
anthoiities; but I belieTe that the whole pathology of the diseases in which the two cha-
nctera aboTO cited are combined is, with rare exceptions, so closely conformed to that of
the tcirrhoiUi and medullary cancers, that they should be included under the same generic
name. The grounds of this belief, which, I think, agrees with the opinions of Rokitansky and
Virchow, will appear in the present lecture; and at its end I will briefly sum them up.
• I believe that either of these forms may occur in any of the parts enumerated as the
usual seats of epithelial cancer; but they are not both equally common in every such part.
The superficial, and especially those which have the characters of wnrty and cauliflower-
like outgrowths, are most frequently found on mucous surfaces, especially those of the genital
organs ; the deep-seated are more frequent in the tongue than elsewhere ; those on the ex-
tremities and in the scrotum have usually a well-marked warty character, and are mrely
deep-seated. Other particulars might, I believe, bo stated, but I am unwilling to state them
unsupported by counted numbers of cases.
566 SUPERFIOIAL EPITHELIAL OANOBB^
part derive a peculiar character from the share which the papillse of the
skin or mucous membrane take in the disease. These being enlarged,
and variously deformed and clustered, give a condylomatous appearance
to the morbid structures, which has led to their being called papillary
or warty cancers, and which renders it sometimes difficult to distinguish
them from common warty growths. According to the changes in the
papillae, numerous varieties of external appearance may be presented:
I shall here describe only the chief of them.
In the most ordinary examples of epithelial cancer of the lower lip, or
of a labium, or of the scrotum in the soot-cancers, if they be examined
previous to ulceration, one can feel an outspread swelling, and an unna-
tural firmness or hardness of the affected skin. The width and length
of the swelling are much greater than its thickness. The diseased part
is enlarged; the lip, for example, pouts, and projects like one overgrown;
and the swelling is slightly elevated, rising gradually or abruptly from
its borders, and haying a round or oval or sinuous outline. Its surface,
previous tg ulceration, may be nearly smooth, but more often is coarselj
granulated, or tuberculated, or lowly warty, like the surface of a syphi-
litic condyloma, deriving this character usually from the enlarged and
closely clustered papillae. The surface is, generally, moist with ichorous
discharge, or covered with a scab, or with a soft material formed of de-
tached epidermal scales. The firmness or hardness of the diseased put
is various in degree in different instances: it is very seldom extreme;
the part, however firm, is usually flexible and pliant, and feels moderately
tense and resilient on pressure. Commonly, it is morbidly sensitive, and
the seat of increased afflux of blood. Its extent is, of course, various;
but, before ulceration, the disease makes more progress in length and
breadth than in depth ; so that when, for example, it occupies the whole bor-
der of a lip or of a labium, it may not exceed the third of an inch in thickness.
In the form of epithelial cancer just described there may be no consi-
derable enlargement of papillae, or it may only appear when the growth
is cut through. But, in many instances (especially, I think, in the epi-
thelial cancers of the prepuce, glans, and integuments of the extremities), «
the changes of the papillae are much more evident. In some, as in the
adjacent sketch, one sees a great extent of surface covered with crowds
and clusters of enlarged papillae set on a level or slightly elevated por-
tion of the cutis. Singly (when the ichor and loose scales that fill, their
intervals are washed away), they appear cylindriform, flask-shaped, pyri-
form, or conical : clustered, they make nodulated and narrow-stemmed
masses. They may be in one or in many groups ; or groups of them
may be scattered round some large central ulcer. They appear very
vascular, and their surface, thinly covered with opaque white cuticle, has
a pink, or vermilion, or brightly florid hue.*
• Museum of St. Bartholomew's, Ser. I 42, 12G, 127, &c., and Ser. xi. 6. Mus. CoU.
Surg. 2301, 2607, 2008, &c.
IXTBSHAL CHARAOTBBS. 56T
la otber iiutaiices, or in other parte, a large mass is formed, the snr-
(tee of which, vhen expoBed by washing away the loose epidennoid cells
vfaich fill up its inequalities, is largely granulated or tnbercnlated, and
B planned out into lobes by deeper clefts. Such growths are upraised.
eaoMower-like ; and, with this likeness, may be broken through the clefts,
mto narrow-stemmed maBseB, formed each of one or more close-packed
gronps of enlarged, tuberous, and clavate paplllse-f The surface of such
a growth shows, usually, its full vascularity ; for if it be washed, it appears
bare, and, like the surface of common granulations, has no covering layer
of cuticle. It may be florid, bleeding on slight contact, hut, more often,
it presents a dull or rusty vermilion tint, rather than the brighter crimson
or pink of common granulations, or of such warts as one commonly sees
on the prepuce or glans penis.
Occasionally we meet with an epithelial cancer having the shape of a
sharply-bordered circular or oval disk, upraised from one to three lines
above tho level of the adjacent skin or mucous membrane, and imbedded
in about the same depth below it. The surfaces of such disk-shaped
cancers are usually fiat, or slightly concave, granulated, spongy, or irre-
golarly cleft ; their margins are bordered by the healthy integuments,
rused and often slightly everted by their growth. Such shapes
are not nnfrequent among the epithelial cancers of the tongue, of the
lining of the prepuce, and of the scrotum. I removed such an one, also,
from the perineum, and have seen one in tho vagina.
Sometimes, again, an epithelial cancer grows out in the form of a
cone. I examined such an one removed from the lower lip, which was
half an inch high, and nearly as much in diameter at its base. Its base
* The papillary chancier ia well abown in the specimen of soDt^cancei ot the hand, in
the Mtueiun ot St BaTtholomew*! (Ser. li. G), which is lepreBonted in ilg. 98. The hiMory
oTtha caaeiiin PotU'a Works, by Ear1e,iii. 1S2. The patient was a gardener, who had been
empkiyed in (Irewing sool for several mornings: (he disease wu of five years' duration.
t MoMum of St. Bartbolomew's, Ser. zxx. 39. Hus. CoIL Surg. 2009.
568 BUPBBFIOIA.L EPITHELIAL OAHCIE.
was a cancerona portion of catie ; its Babstance vaa fino, gray, oottpoK^
of the OBuol elements of epithelial cancers imbedded among fihm rrlNhr
and elastic tissue outgrown from the skin : the rabcataoeona tiwiu «M
healthy. In another instance an exactly similar cancer grew ca ft
chimtey-BWeep'eiieck;i'aiidinboth these cases, the growth, being cotbW
with a tliick laminated black and brown scab, was, at fint, not atj
to distinguish from syphilitic mpia : that in the neck might em ban
been confounded (as some, I believe, have been) with one of tk« i*rM
that grow from diseased hair follicles. Mr. Curlingf describea a stBiW
growth, three-quarters of an inch long, on tbe scrotum of a chimuj^
sweep ; and has copied, from one of Mr. Wadd's sketches, a reprewu^
tion of a horn 2^ inches long similarly formed.
_ _ Lastly, we may find epithelial cancers as nam*-
stemmed or even pendulous growths from the cnliL I
have seen such on the lower lip, and at the anni, bkt
masses of very firm ezaberant granulations, two tocbi
in diameter, springing from narrow bases in the cm
or deeper tissues, and far oTerhauging the adjacat
healthy skin. And I lately examined one of this kiad,
which was removed from the skin over the Iowa bolder
of the great pectoral muscle. It was exactly like ihi
specimen sketched in fig. 99. It was spheroidal, aboat
an inch in diameter, rising from the skin with a base about half ai widt;
it was lobed, deeply fissured, and subdivided like a vrart, with iu x/m-
ponent portions pyrifom and mutually compressed. Its surface vai
pinkish, covered with a thin opaque-white cuticle, which extended mU
and seemed to cease gradually in the fissures. Its substance, compoftd
almost wholly of epithelial cancer-cells, was moderately firm and elutic.
It was but little painful. A thin, strong-smclhng fluid ooxed from it.
The patient had noticed a small unchanging wart in the place of ihii
growth for ten or twelve years. Without evident cause it had begun u
grow rapidly, and bad become redder and discharged fiuid, six wwb
before its removal. §
It is almost needless to say that a much greater variety of shapes thin
I have here described may be derived from the difi'erent methods sod
■ HuL of St. Bartholomew'*. Id (he oeii fcu the nme patiem vn» in iba botpiti] rA
■ onrenm* wan of the icrotum.
t TcemiM on Diwaiva of ihc Tcslicl?, p. ^33. The ap«f imio ii in ihe Mo*. ColL Svt.
3409. In tba Muiaum of Si. Banholomew'i ii an iniUnce of ver? large noxum. .t
which, ai ihe border* of the ulcer, (here are ipur-ihapeil ■harp-poinied pioaeMLi. dcatalM
canceraui pspills, lonie ot wlilcli are rmm } to J an inch in leagih.
X ^ig. 09. Section of a narmw-liBKd, oulgrowing epithelial rancer. Ii wai emnHlf
ntcular, ami had frown in the place of a dark mole, or pigmentary naema, co ihe v*!!
or ihe abdomen. Two growthi had been preTioiuljr removed from the aine part.
( The cauliflower eicrMcence of the iiterna may be mow nearly romparad wi4**
eiiremely eiubaranl epiilielial cancen, tnch a* are detcribed above (ne p. U7).
INTERNAL STRUCTURE. 669
degrees in which the papillsB are deformed, enlarged, and involved in
the cancerous disease. All, and more than all, the shapes of common
wmrty and condylomatoos growths may be produced. But the same
general plan of construction exists in all ; namely, a certain portion of
the skin or mucous membrane is infiltrated with epithelial cancer-struc-
ture : on this, as on a base more or less elevated aud imbedded, the
pttpillsd, variously changed in shape, size, and grouping, are also cancer-
ims ; their natural structures, if we except their bloodvessels, which
appear enlarged, are replaced by epithelial cancer-cells. And herein is
die essential distinction between a simple or common warty or papillary
growth, and a cancerous one or warty cancer. In the former the papillse
retain their natural structures ; however much they may be multiplied,
or changed in shape and size, they are either merely hypertrophied, or
are infiltrated with organized inflammatory products ; however abundant
the epidermis or epithelium may be, it only covers and ensheathes them.
But in the warty cancer the papillse are themselves cancerous : more or
kfls of their natural shape, or of the manner of their increase, may be
traced ; but their natural structures are replaced by cancer structures ;
the cells like those of epithelium lie not only over, but within, them.*
To describe the interior structure of the superficial cancerous growths,
we may take as types the most common examples of cancers of the lower
Up— those in which the papilla are indeed involved, enlarged, and can-
cerous, but not so as to form distinct or very prominent outgrowths.
The surface of a vertical section through such a cancer commonly pre-
•ents, at its upper border, either a crust or scab, formed of ichor, de-
tached scales, and blood ; or else a layer of detached epidermoid scales,
forming a white, crumbling, pasty substance. This layer may be im-
perceptible, or extremely thin ; but it may be a line or more in thick-
ness, and it enters all the inequalities of the surface on which it lies.
Its cells or scales are not regularly tessellated or imbricated, like those of
the epidermis on a common wart, but are placed without order, loosely
connected both with one another, and with the subjacent vascular struc-
tures, and may be easily washed away.
Such a layer must be regarded, I presume, as formed of epithelial
* I deflciibed the papillary ori^n and construction of these cancers in 1838 (Medical
Gazette, zxiii 284), but was not then aware of their minute structure. Later examinationa
have made me sure that the true distinction between them and other papillary growths is
■s above stated. But it is to be observed that cancerous growths may appear papillary or
warty, though no original papilhe are engaged in their formation. Thus when papillary
cancers are deeply ulcerated at their centres, the base of the ulcer, where all the original
papiUaB are destroyed, may be warty, like its borders where the cancerous papilla) are evi*
dent Some of the most warty-looking epithelial cancers are those which grow from the
deep tissues of the leg after old injuries. Tliis may be only an example of cancerous growths
imitating the construction of adjacent parts ; but in some instances (as in cysts, and on the
nncoiis membrane of the gall-bladder and stomach), the warty cancers are probably ex-
imples of the dendritic mode of growth. It must also be a question, at present, whether
MMne of the mott exuberant cancers of the skin are not to be ascribed to this mode of growth,
b it, to lay the least, extremely difficult to trace their origin from once-natural papillse.
570 IKTEBNAL STBUOTUBB.
cancer-cells, detached or desquamated from the sabjacent vascular and
more perfectly organized substance of the cancer. This substance pre-
sents, in most cases or in most parts, a grayish or grayish-white color,
and shines without being translucent. It is firm and resilient, close-tex-
tured, and usually void of any appearance of regularly-lobed, granular,
or fibrous construction, except such as may exist near its surface, where
close set and uniformly elongated vertical papillae may make it look
striped. The grayness and firmness are, I think the more uniform and
decided the slower the growth of the cancer has been. In the acnte
cases, especially of secondary formations, or when the cancer has been
inflamed or ulceration is in quick progress, the cut surface maybe opaque
white, or of some dull yellow or ochre tint, streaked and blotched with
blood ; or it may, in similar cases, be soft and shreddy, or nearly bram-
like ; but these appearances are very rare.
The gray substance of epithelial cancers commonly yields to pressure
only a small quantity of turbid yellowish or grayish fluid : but with rare ex-
ceptions, one may squeeze or scrape from certain parts of the small cayities
or canals, a peculiar opaque-white or yellowish material. It is like the
comedones, or accumulated epithelial and sebaceous contents of hair-fol-
licles ; or even more like what one may scrape from the epidermis of the
palm or sole after long maceration or putrefaction. This material, which
is composed of structures essentially similar to those of the firmer suh-
stance of the cancer, but differently aggregated, supplies one of the best
characteristics of the disease. It may be thickly liquid, but more often
is like a soft, half-dry, crumbling, curdy substance : pressed on a smooth
surface, it does not become pulpy or creamy, but smears the surface, as ^
if it were greasy ; mixed with water, it does not at once diffuse itself, so
as to make the water uniformly turbid, but divides into minute visible
particles.*
The quantity of this softer material is extremely various in diffierent
instances of epithelial cancer. According to its abundance and arrange-
ment, the gray basis-substance may appear differently variegated ; and
the more abundant it is the more does the cancer lose firmness, and ac-
quire a soft, friable, and crumbling texture. In many cases the soft sub-
stance appears, on the cut surface, like imbedded scattered dots, or small
grains, these being sections of portions contained in small cavities. But,
as the quantity increases, and the cavities containing it augment and
coalesce, so the firmer substance becomes, as it were, cribriform ; or when
the softer substance is washed away, it may appear reticulated or sponge-
like, or as if it had a radiated or plaited structure. Or, lastly, the soft
substance may alone compose the whole of the cancer : but this, I think,
* In these are its distinctions from the "juice" of either scirrhous or medullary cancers.
But it must be remembered that, in the rare instances in which epithelial cancers are very
floft, they may yield a creamy or turbid grayish fluid. It can hardly be necessary to give a
oantioD againat confounding the peculiar material described above with that which may be
jprenod from mUk-ducts involved in scirrhous cancers (compare p. 498).
8TATB OF THE TISSUES INVOLVED. 571
vrj rarely the case, except in secondary formations and in the lym-
tic glands.
ertical sections of the more exuberant and the more distinctly papil-
epithelial cancers present essentially the same appearance as I have
aibed. The npper border, corresponding with the exposed part of the
irth, may be overlaid with a thin scab or crust, or epidermoid scales,
hched and disorderly, or may be bare, like that of a section of common
filiations. The cut surface is generally gray, succulent, and shining,
I distinct appearances of vascularity. Portions of it may yield the
iliar soft crumbling substance like macerated epidermis ; but this is, I
ik, generally less abundant than in the less exuberant and deeper-set
nmens, and is more often arranged in a radiated or plaited manner.
lie vertical sections of the superficial epithelial cancers of the integu-
its display many important differences, in relation to the depth to
sh the cancer-structures occupy the proper tissues of the skin or
toils membrane.
n some, only the papillae, or the papillse and the very surface of the
le on which they rest, appear to be involved. The enlarged papillae,
nch cases, usually retaining their direction and their cylindrical or
derly-conical shape, appear like fine gray stripes or processes verti-
f raised on the healthy white tissue of the integument, or on its
'ace rendered similarly gray by cancerous infiltration. And the out-
B of the papillae are commonly the more marked because of their con-
t with the opaque-white substance formed by the epidermoid scales
sh cover them and fill up all the interstices between them. In such cases,
cancerous material may be more abundant on the surface than in the
itance of tKe papillae or corium ; and often the whole morbid substance
rittle, and may be separated from the corium which bears the papillae.
tot more frequently, and almost always in such cases of epithelial can-
when they are removed in operations, the cancerous structures are
6 deeply set. They occupy the whole thickness of the integument,
each to a level deeper than it. The base or lower border of the dis-
)d mass rests on, or is mingled with, the subcutaneous or submucous
les, whatever these may be, — fat, muscular fibres, or any other. The
ral borders usually extend outwards for some distance, on each side,
Bath the healthy integuments which bounds the upraised part of the
ased growth, and which is usually raised and everted so as to over-
g the adjacent surface. In nearly all these, also, while the surface
central parts of the cancer are being destroyed by ulceration, its
> and borders are, at a greater rate, extending more deeply and widely
he subcutaneous or submucous tissues.
rhe bases of the most exuberant and most distinctly papillary cancers
rarely, in the early periods of their growth, either deeply or widely
in the integument. They rarely, I believe, occupy more than the
kness of the portion of the skin or mucous membrane from which the
572 SUPERFICIAL EPITHELIAL CANCBB.
growths spring: they sometimes occupy less. But, in their later growth,
and especially when ulceration is progressive, the same deeper and wider
extension of the base of the cancer ensues as I mentioned in the last pan-
graph.
AH the foregoing description will have implied that the proper stnio-
tures of the diseased parts are mixed up with the cancerHStructoreB in-
serted among them : the condition of parts is here exactly comparable with
that of other cancerous infiltrations. (Compare p. 493 and 500.) The
boundaries of the cancer, as seen in sections, usually appear to the naked
eye well-defined; yet it is often easy to see portions of the natural dssoei
extending into it, these being continuous with those portions among whidi
the cancer-structures are infiltrated. This is especially evident when, u
in the lip or tongue, the superficial muscular fibres are involved. F^e
red bands may then be traced into or within the cancer ; and the micro-
scope will prove, if need be, their muscular structure. Or^ when theie
cannot be traced, yet we may find the fibro-cellular and elastic fibres of
the involved skin or mucous membrane.
Concerning the changes that ensue in the tissues thus involved in the
deeper parts of epithelial cancers, I believe that what was said of those
in cancerous breasts (p. 493 and 500) might be here nearly repeated,
regard being had to the original differences of the tissues in the respec-
tive cases. In general, the natural structures in these cases appear not
to grow ; gradually, but not all at the same rate, they degenerate and
are removed, till their place is completely occupied by the increasing can-
cer-structures, and an entire substitution is accomplished. So, too, what
was said of the stroma of scirrhous cancers of the breast might be repeated.
These epithelial cancers have no stroma of their own ; their proper
structures are sustained by the remains of the original textures of the
afiected part. And, as in the scirrhous cancers, so in these ; when they
grow very quickly, they occupy a comparatively small area of the orip-
nal tissues, and may appear like nearly distinct tumors.
In the most exuberant epithelial cancers, and in those that are promi*
nent, like warts or condylomata, there is more growth of the natural tissues;
those, not of the papillae alone, but of the basis of the skin or mucous
membrane, may be traced into the outgrowth, forming a stroma for the
cancer-structures, and surmounted by the cancerous papillae. Such a
stroma may be well traced in many soot-cancer-warts : the fibro-cellular
and elastic tissues extend from the level of the cutis, in vertical or radia-
ting and connected processes among which the cancer-cells lie ; and one
may compare them with the osseous outgrowths that form an internal
skeleton of a cancer on a bone (see p. 534).
The tissues bordering on the superficial epithelial cancers appear gene-
rally healthy, but they are often increased in vascularity, and succu-
lent. The adjacent corium also may appear thickened, with its papillie
enlarged, and an unusual quantity of moist opaque-white cuticle may
BBBP-SEATBD EPITHELIAL CANOEB. 578
cover them.* This condition is, however, not frequent ; neither is it
peculiar to the environs of cancer ; changes essentially similar are often
observed around chronic simple ulcers of the integuments*!
The deep-seated epithelial cancers remain to be described. In the
progress of all the preceding varieties of the superficial form of the dis-
ease, especially when their surfaces are ulcerating, we may trace a con-
stant Bubintegumental extension of their basis, in both width and depth ;
an extension which is more than commensurate with the destruction at
the surface, and in the course of which no tissue is spared. Now, the
same cancerous infiltration of the subcutaneous or submucous tissue,
which is thus the common result of the extension of the disease from the
surface, may also occur primarily : that is, the first formation of- epithelial
cancers may be in masses of circumscribed infiltration of the tissues
beneath heidthy skin or mucous membrane. The same condition is more
frequent in the* epithelial cancers that form, as recurrences of the disease,
near the seats of former operations, or, as secondary deposits, about the
borders of primary superficial growths.
In comparison with the superficial form, the primary deep-seated
epithelial cancer is a very rare disease ; yet it is frequent enough for mo
to have seen, within the last year, three cases, which I will describe ; for
they were all well-marked examples.
A chimney-sweep, 82 years old, died suddenly, suffocated, in the night
after his admission into St. Bartholomew's.
He had had cough for six months, and aphonia and dyspnoea for two
months. A scrotal soot-cancer had been removed from his brother in
the previous year.
I found a wide-spread layer of firm substance, exactly like that of
the majority of epithelial cancers, under the mucous membrane of the
lamyz, involving the left border of the epiglottis, the left arytenoid car-
tilage, the intervening aryteno-epiglottidean fold, part of the right
arytenoid cartilage, and the upper and posterior third of the left ala of
the thyroid cartilage. In all this extent, the diseased substance lay
beneath the mucous membrane, which, though very thinly stretched over
some parts of it, appeared healthy, was covered with ciliary epithelium
wherever I examined it, and could everywhere be separated in a distinct
layer.^ All the submucous tissues were involved ; the cartilages, as it
* M. Lebert (Trait4 Pratique, p. 618) quotes iVom M. Follin, that the tissues around the
dlif te ere often " infiltrated with epidermis in a diffuse manner."
t On loma of the diseases of the papillss of the cutis (Medical Gazette, vol. xxili. p. 285).
The multiform appearances of epithelial cancers which I have described may be still more
Tuied by the consequences of degeneration and disease. But it would be too tedious to
dMcribe them minutely, while, as I believe, they are essentially similar to the consequences
of die tame afbctioDs in Ae scirrhous and medullary cancers, of which I have already given
•ome Bocoimt
{ The fpeeimen, and those referred to in the two fbllowiog cases, are in the Museum of
St Budiolaniew'i.
574 DBEP-BBAIES EPITHELIAL OANCIB.
were buried in the growth, appeared leas changed thui the softer parts.
The aurface of the growth, as covered with the mucotu membrane, lu
lowlj-lobed, or tuberculated, raised from one to two lines abore the natnnl
level ; its border was in many parts sinuous. The cancerous substanct
was firm, elastic, compact, grayish and white, shining, variously marked on
its section with opaque-white lines. It appeared wholly composed of the
usual minute structures of epithelial cancers, including abundant lamiutid
epithelial capsules. All the epithelial structures were of the BcalfrHkt
form, though collected in the tissues under a membrane coTSredvilk
ciliary epithelinm.
A man was admitted into the Hospital, in a dying state, with a lugs
firm swelling between the lower j>t
■^- ^•*- and the hyoid bone, the increa« U
which had produced great difficult; of
breathing and swallowing. After hii
death, the greater part-of the sweUiog
was found to be due to cancer of the
deep tissues of the tongue^ and of the
fauces and lymphatic glands. A ttc-
tion of the parts (as in fig. 100) sWed
that the muscular and other Btmctnra
of the posterior two-thirds of the tongae
were completely occupied by a firm on-
cerous infiltration : but the mucous mem-
brane of the tongue was entire; iu
various papillary structures only irere
healthy and distinct; it was tight-
stretched and adherent on the surface
of the cancer. From the base of the
tongue the cancer extended backwardi
and downwards on both sides of the
fauces, and as far as the vocal cords,
preserving in ita whole extent the chi-
racters of a masdve infiltration of all
the submucous tissues. It was covered
with healthy-looking mucous membrane
in every part, except just above the right vocal cord, where it protmded
slightly through a circular ulcer less than half an inch in diameter. The
substance of the disease presented, to the assisted as well aa to the un-
aided sight, and touch, the well-marked characters of epithelial cancers.
The lymphatic glands were similarly diseased.
A gentleman, 64 years old, had, on tho upper part and right side of his
nose, a flat, lowly-lobed or tuberculated growth, an inch m diameter,
gradually rising above the level of the adjacent skin, to a height of li
mr 2 lines. It was covered with skin, which was very thin and adhe-
natf and florid with. amaW ^a.lA&. \)\wA'^«»£lfi, like those in the skin
ULCERATION. 676
f his cheek. The base of the growth rested on the bones ; it felt like
n infiltration of all the thickness of the deeper part of the skin and
obcutaneons tissnes, and moved as one broad and thick layer of morbid
nbstance inserted in the skin. In its middle and most prominent part
ras a fissure nearly a line in depth, with black, dry borders, from which
b very slight discharge issued. It was very painful, and, beginning
Tom no evident cause, had been ten weeks in regular progress.
I removed this disease, and found in its centre a small, roundish mass
>f soft, dark, grumous substance, like the contents of a sebaceous cyst."*"
/Lround the cavity in which this was contained, all the rest of the disease
ippeared as an outspread infiltration of firm yellowish and white cati-
serous substance in the tissues under the stretched and adherent but
mtire skin. It extended as deep as the periosteum of the nasal bones.
Soft, crumbling, and grumous substance could be scraped from it ; and
it yielded well-marked elements of epithelial cancer, with numerous
laminated capsules. During the healing of the operation-wound, a
nmilar small growth appeared in the adjacent tissue. It was destroyed
with caustic by Mr. Hester, and the patient has remained well : but only
a few months have yet elapsed.
Besides cases such as these, which may suffice for a general description
of the disease, many might be cited, of what may be regarded as an
intermediate form, in which both the skin or mucous membrane and the
subjacent tissues are simultaneously affiBCted, but the latter to a much
larger extent than the former. Such cases are far from rare in the lower
lip and tongue. They are characterized by the existence of a roundish,
firm, or hard and elastic lump, deep-set in the part, well-defined to the
touch, with its surface little, if at all, raised, and having at some part of
its surface either a portion of cancerous integument, or a small ulcer or
fissure.
. Now these cases of deep-seated epithelial cancers have much interest,
as well in practice as in their bearing on the pathology of the disease.
They are instances of the disease of which it is impossible to speak as
of mere augmentations of the natural structures ; there is in them no
trace at all of the assumed homology of epithelial growths ; there is in
them no progressive formation of epithelial cells gradually penetrating
from the surface into the substance of the cutis ; their progress, or a
part of it, is from the deeper parts towards the surface.
The epithelial cancers in or near the integuments are so prone to ulce-
ration, that the occasions of seeing them as mere growths are compara-
tively rare. The state in which they are usually shown to us is that of
progressive ulceration of the central and superficial parts, with more
tiian equal growth of the bordering and deeper parts. In this state,
* Mr. Heiter and Mr. Rye, who saw this case some weeks before I did, told me that it
pictentad, at fint, aU the characters of a common sebaceous cyst ; and I think it quite pro-
bable that it waa an example of epithelial cancer formed in and around such a cyst.
576 EPITHELIAL OAKOBB.
indeed, they present the type of that which is commonly described as
the cancerous ulcer ; a type which is observed, also, in some examples
of the scirrhous cancer (p. 518), and more rarely in the medullary.
In the superficial first-described form of the disease, the nleerstion
usually begins either as a diffuse excoriation of the surface of the cancer,
the borders of which are alone left entire, or else as a shallow ulcer ex-
tending* from some fissure or loss of substance at which the disease com-
menced. The discharge from the excoriated or ulcerated surface usually
concretes into a scab, or a thicker dark crust, beneath which, as well as
beyond its edges, ulceration gradually extends in width and depth.
A nearly similar method is observed, I believe, in the earliest ulcera-
tion of the papillary and other more exuberant epithelial cancers. Tbe
central parts ulcerate first, and the ulcer from this beginning deepens
and widens, destroying more and more of the cancer-stmctmres ; bat its
rate of destruction is never so quick as that of the increase of the
borders and base of the cancer.
In the deep-seated epithelial cancers, other methods are obserred in
the first ulceration. Sometimes the skin or mucous membrane orer
them, becoming adherent and very thin, cracks, as it may when adh^
rent over a scirrhous cancer (p. 517). Such a crack may remain long
with little or no increase, dry and dark, and scarcely discharging; bat
it is usually the beginning of ulceration, which extends into the mass of
the cancer. In other cases, with inflammation of the cancer, its central
parts may soften and perhaps suppurate ; and then its liquid contents
being discharged (sometimes with sloughs), through an ulcerated opening
or a long fissure, a central cavity remains, from the uneven walls of
which ulceration may extend in every direction. And again, in other
cases, especially, I think, in secondary formations, and in those under
e'le scars of old injuries, the cancer protrudes through a sharply-bounded
cer in the sound integument or scar, and grows exuberantly, with a
soft shreddy surface, like a medullary cancer, or with a firmer, warty or
fungous mass of granulations.
But though the beginnings of the ulcers be thus, in different instances,
various, yet in their progress they tend to uniformity. The complete
ulcer is excavated more or less deeply, and usually of round, or oval, or
elongated shape. Its base and borders are hard, or very firm, because,
as one may see in a section through it, they are formed by cancerous
substance infiltrated in the tissues bounding it. The thickness of this
infiltration is, commonly, in direct proportion to the extent of the ulcer,
from a line to half an inch or more : we may feel it as a distinct and
well-defined indurated boundary of the whole ulcer, hindering its move-
ment on the deeper tissue. The surface of the base of the ulcer is
usually concave, unequal, coarsely granulated, nodular, or warty : it is
florid, or often of a dull vermilion, or rusty-red color; it bleeds readily,
but not profusely ; and yields a thin ichorous fluid, which is apt to form
scabs, and has a peou&^ixV^ ^\.TO\i^^ ^^[^w&ivQ odor, something like that
ULOEBATIOK. 577
of the moBt offensive cutaneous exhalations. The borders of the ulcer, or
some parts of them, are, generally, elevated, sinuous, tuberous, or nodu-
lated; frequently, they are everted, and, to a less extent, undermined.
They derive these characters, chiefly, from the cancerous formations be-
neath the skin or mucous membrane that surrounds the ulcer. These for-
mations may be in a nearly regular layer, making the border of the ulcer
like a smoothly rounded embankment ; but oftener, though continuous
all round the idcer, they are unequal or nodular, and then corresponding
nodules or bosses, from a line to nearly an inch high, may be raised up
round the ulcer or some part of it. Moreover, these upraised borders
may so project as to overhang both the base of the ulcer and the adja-
cent healthy surface of the skin or mucous membrane ; they thus appear,
at once, undermined and everted. When they are everted, healthy skin
is usually reflected under them, and continued beneath them to their
extreme boundary. When the papillary character of the primary
groifth was well-marked, the borders of the ulcer often present, instead
of the characters just described, a corresponding papillary or warty
structure : for in these cases, the cancer continues apt to affect espe-
cially the papillae, and widening areas of them become its seat as it
extends. And, even at the base of the very deep ulcers, the cancerous
granulations, though rising from the tissues far deeper than papillse, may
have a similarly warty construction.
The characters of the ulcer here described, are generally retained,
however deep, and into whatever tissues the cancer may extend. For
the proper tissues of the successively invaded parts, at first infiltrated
with cancer-structures, seem to be quickly disparted and then removed :
even the bones rarely produce any outgrowths corresponding with those
ihat are found in medullary cancers ; they become soft, are broken up,
and at length utterly destroyed. Epithelial cancers thus extending pro-
duced the changes described, as characteristic of malignant ulceration,
in p. 327 ; and by similar extension (especially in the affections of the
lymphatic glands), they lay open great bloodvessels more often than any
other ulcers do. I have seen three cases in which the femoral artery
was thus opened by ulceration extending from the epithelial-cancerous
inguinal glands.
The minute component structures of the epithelial cancers are alike
among all the varieties of construction and external shape that I have
now described ; and, if we omit the proper textures of the part affected,
they may be thus enumerated : (a) epithelial cancer-cells ; (b) nuclei,
either free, or imbedded in blastema ; {c) endogenous or brood-cells ;
(d) laminated epithelial capsules, or epithelial globes. From each of
these, by degeneration or other change, several apparently different
forms may be derived. The proportions, also, in which they are com-
bined are various in different specimens ; but I believe that diversities of
appearances to the naked eye are not so connected with these propor-
87
678
EPITHELIAL OAKOBB.
tions, as mth the methods of arrangement, the degrees of degeneri-
tion of the component structures, and the mingling of the productB rf
inflammation in the cancer.
(a) The most frequent cells (fig. 101, a), and those which maj be
regarded as types, are nucleated, flattened, thin and scale-like. Thej
are, generally, round or round-oval ; but they seldom have a regular
shape : their outline is, usually, at some part, linear, or angular, or
extended in a process. Their average chief diameter is about ^^jf of an
inch; but they range from v^J^ to jjojiy or perhaps beyond these limits.
In the clear, or very palely nebulous cell-contents, a few minute granules
usually appear, either uniformly scattered, or clustered, as in an areola,
round the nucleus.
The nucleus is usually single, central, and very small in comparison
with the cell, rarely measuring more than ^^'^^j of an inch in its longest
diameter : it is round or oval, well deflned, subject to no such varieties of
shape and size as the cell. It is usually clear and bright, and is often
surrounded by a narrow, clear area ; it may contain two or more minute
granules, but rarely has a bright, distinct nucleolus.
But many of the cells may deviate widely from these characters; the
most various and (if the term may be used) fantastic shapes may befoond
Fig. 101 .•
B
mingled together. The younger cells are generally smaller, rounder,
more regular, less flattened to the scale-like form, clearer, and with com-
paratively larger nuclei. The older (as I suppose) appear drier and more
filmy ; they are often void of nuclei, and like bits of membrane in the
shape of epithelial scales (b) : they are flimsy, too, so that they are often
wrinkled or folded and rolled up, so as to look fibrous (c). Independently
of differences of age, some cells are prolonged in one, two, or more
slender or branching processes ; some are very elongated (as d) ; some
are void of nuclei ; some, within their pale borders, present one or two
dimly-marked concentric rings, as if they had laminated walls.
To these varieties may be added such as depend on the progressive
degeneration of the cells. The most frequent (besides the withering,
which, I suppose, is shown in the shrivelled, flimsy scales, without nuclei,
just mentioned) is the change like fatty degeneration in other cancer-
structures. One of the most frequent effects of such degeneration is,
that the place of the nucleus is occupied by a circular or oval group of
* Various epltheUaV canceT^«\\« oi «ica\^. llVa.%Tv\^<&d 350 times : referred to in tlie text
MINUTB 8TRU0TURBS. 679
minate oily-lookiDg moleculeSy some bright with black borders, some dark
(fig. 102). Others, like these, or larger, are generally scattered throngh
the cell. With the progress of the degeneration, all trace of the nucleus
18 lost ; the molecules increase in number and in size, till the whole cell or
scale appears filled with them, or is transformed into an irregular mass
of oily-looking particles, differing in shape alone from the common
granule masses of fatty degenerations.
Tig. 102.*
(i) Nuclei either free or imbedded in a dimly-molecular or granular
basis, are commonly found mingled with the cells. I believe they occur
in the greatest abundance in the most acute cases. They may be just
like the nuclei of the cells ; but, usually, among those that are free, many
are larger than those in the cells ; and these, reaching a diameter of
more than ^^qj^ of an inch, at the same time that they appear more vesi-
cular and have larger and brighter nucleoli, approximate very closely to
the characters of the nuclei of scirrhous and medullary cancer-cells.
Indeed, I have seen many nuclei in soot-cancers, which, if they had been
alone, I could not have distinguished from such as are described at page
497 : yet all the other structures of these specimens were those usual in
epithelial cancers, and between the different characters of nuclei there
were all possible gradations. The free nuclei, like the cells, may be
found in all stages of degeneration (fig. 102).
(<?) Those which are named brood-cells, or endogenous cells, present
many varieties of appearance, which may be regarded as the results of
one or more nuclei, enclosed within cells assuming, or tending to assume,
the characters of nucleated cells (fig. 103).t In some cells a nucleus
appears very large, clear, pellucid, spherical : it loses, at the same
time, its sharply-defined outline, its boundary becomes shadowed, and
it loqks like a hole or vacant space in the cell (a). Thus enlarging, the
nucleus may nearly fill the cell, and appear as a pellucid vesicle. I think,
however, that such nuclei rarely grow to be cysts, like those whose history
is described in the twenty-second lecture (p. 336) ; for cysts containing
serous or other fluids are very rarely found in epithelial cancers. Neither
have I seen instances of free nuclei changed, as those in the cells are.|
* Cells and free nuclei of epithelial cancer, in states of fatty degeneration. Magnified
350 times.
t We owe the ability to interpret these appearances, which illustrate many thin«;s interest
ing in the general physiology of cells, almost entirely to Virchow (in his Archiv, iii. 197),
and Rokitansky, L c. Other facts, derived from the examination of solid tumors, and illus-
trating the capacity of the nucleus for development, are in pages 426, 453, 538 : all these
may deserre study in physiology, together with the doctrine of cyst-formation explained at
p. 336, etc.
X Vixubow, however (WOrzburg Verhandl. i. 100), mentions having foimd, in a cauli-
580 EPITHKLIAL CAKOBB.
The enlarged nucleus may remain completely pellucid or barren ; Wt
often granular matter appears to fill it, and, as often^ one or two cor-
puscles appear to form in it, which now appear as its nuclei, and make it
assume the character of a cell, endogenous within the first or parent-^
(b). The sketches show many of the appearances that may be benoe
derived ; and others may be thus explained. When a cell contains two
Fig. 103 .•
nuclei, one only of these may enlarge or become inflated (if I mij use
such a term for that which fills with liquid, not with air) ; the other maj
be then pressed against the wall of the cell. Or both nuclei maj alike
proceed to the grade of cells, and two cells, flattened at their place of mutul
compression, appear within the parent-cell (c) : or a secondary nuclcks
t. e. one formed within an enlarged nucleus, may enlarge like its prede
cessor, and become like a pellucid cavity, or may become a secomlarT
cell, and contain its tertiary nucleus : hence, possibly, the concentric ap-
pearance above mentioned may be referred to the scries of successiTrli
enclosed cell-walls (d). And changes such as these may equallv uoco
with more than two nuclei : a cell of any grade, primary, secondary, or
later, may be filled with a numerous ** brood** of nuclei, in which all lie
above-described changes (but not the same in all) may be repeated.
{(1) The laminated capsules, as I have called them (''globes cpiJtr-
miques'* of Lebert), are the most singular and characteristic structun^
of the epithelial cancers (fig. 104). They are not, indeed, peculiar to this
disease ; for I have found exactly corresponding structures in the coa-
tents of an epidermal and sebaceous cyst; and so has V. Barenspmn;: ;*
and I have illustrated a corresponding mode of formation in some of the
many-nucleated cells of myeloid tumors (fig. 7G, p. 453). However, thrj
are nowhere so frequent or so well marked as they are in nearly evm
epithelial cancer.
Their great size at once attracts the eye : they are visible even to
flower excrescence of the iiteru?, alveoli which, after the plan of the proliferou* crti\ '■»«■
tained secomlary papillnry growths. The analogy of other proliferous cysts may inJK^*
that these, al>o, originated in niicleL
• Epithelial cancer-cell.*, with endogenous development of nuclei, as deirribeil tf» ike
text. Magnifletl 350 times.
t As quoted by Virchow (Archiv, iii. 2(X)). I have said (p. 453) that I hare oeTrr »««>
such structures in medullary cancers. Rokitnnsky delineates some (Uelier die Cy-**". f ^
9, 10, 11), but Willi less perfect structures than are common in epithelial cancers. I •«"'■*
add, that what was said in p. 453 respet'ting the rarity of endogeiKnis cellf in m«*lul^
cancers relates only to such as occur in external parts; I must believe Ihxn the repmti oi
others, that they are more frequent in cancers of internal organs.
I
UIKCIB SIBDCTCBES. 681
the unaided sight, especially when the softer curdy material of the
cancer, in which they are generally most abundant, is preaaed out on
glass. They appear, at first sight, like spherical or oral cysts, from
t4b to tin of an inch in diameter, walled in by irregular fibrous tissne,
utd containing granular matter, nuclei, or cells, obscurely seen within
them (fig. 104, c). They may be clustered together in a mass or a long
cylinder (d) ; but, by breaking them up, or looking more closely, it
becomes evident that the appearance of fibrous tissue is due to one's seeing
the edges of epithelial scales, which, in ' successive layers, are wrapped
round the central space. Sach scales may be broken off, in gronps of
two, three, or more, retaining the curved form in which they have lain
(fig. 104, a). When detached, they generally appear like the driest and
most filmy of the epithelial scales composing tbe rest 'of the cancer (b):
often they are folded, and look fibrous, even when separated ; their nuclei
are shrivelled or not visible; their contents are often granular. As they
Ue soperposed, they appear closely compacted ; but not onfreqaently gra-
nules are distinct in the oater laminar spaces, or on the inner surface of
detached pieces
Tbe contents fillmg the central spaces in these laminated capsules are
extremely various , sometimes, or partly, granular and oily particles
diffused m some nebulous material ; more often, or with these, cells or
nnclei (c, d) Sometimes one cell is thus enclosed, sometimes two or more :
and these not scale-like, but oval or round and plump, having distinct
and generally large nuclei ; or a crowd of nuclei may be enclosed : uid
briefly, these nnclei may appear in any of those various states which I
described just now in the account of the endogenous epithelial cells.
Indeed it is probable that the last sentence of that deacription (p. 579)
might begin the history of the development of these capsules; for I
know no method of explaining them, except that taught by Rokitansky,
and illustrated by the diagrams copied here (fig. 105).t
In one of tbe simplest coses, we may suppose a nucleus largely inflated
* Rg. 104. lamiDBled cpiihelial capsules, ilfscribed in the text, mugnified about SSOlimBt.
t Fiom U* M«y, Uebei die Cyate; fig. S.
582
BPItHELIAL CAIT08B
Bud filled with a brood of (say four) secondary naclei, which proceed to
the fonnation of secotidary celle (fig. 105, a). If, now, only one of th«
nncloi of these secondary cells becomei
A. ^* ""■' B enlarged, it will not only extend its en
cell's wall into contact with that of the cell
containing it, but will at the same ^e
press the three other cells into similar coo-
tact, and thus appear invested with Iimi-
nated epithelial Bcalee. Such a state, vith
the nuclei of the investing scales, is showo
in B. A greater complexity of umilir
events b shown in c, in which, among t
very large number of secondary ondc^tn-
ous nuclei, many are persistent as mela,
while others, developed to nucleated celli,
are laminated around them. But amoog
the nuclei, two are represented as enlarged
and contuning tertiary " broods" of nnclei,
among which the same changes hare ensued
as in the preceding generation. And it is evident that if any in th*
group a had now singly enlarged, the rest, with all the cells and nnclei
around them, must have arranged themselves or been compressed into
imbricated scales, so as to form a large laminated capsule.
The component Htmotures now described appear to be disorderlj
placed in the mass of epithelial cancer, in the interstices of the natursl
stnietures, or of their remains. I have never seen any of them within >
natural structure, e. g. within a muscular fibre. The laminated capsules
are, I believe, most abundant in tlie softer substance, but they are not
confined to it. The texture of tho mass is such as makes it very difficult
to obtain a sufficiently thin section with the structures undisturbed ; but
in sections of scrotal cancers I have seen the laminated capsules imbedded
at distant intervals among tho simpler epithelial structures, and the tur-
gid large capillaries ascending towards the surface and forming near it
simple or undulating loops. The epithelial structures appeared to he in
contact with the w^ls of the bloodvessels, supported by a wide sparing
meshwork of fibro-cellular tissue growing up from the adjacent tissue of
the scrotum.
In whatever part or organ they may be found, there is a remarkable
uniformity in the characters of the epithelial cancer-structures. Devia-
tions, however, from such as I have described as the normal structurea
are sometimes found. I have once seen a melanotic epithelial cancer :
it grew in the deeper part of tho cutis and in the subcutaneous tisfiie,
under a dark pigmentary nacvus or mole, in a woman who had many simi-
lar moles on various parts of her body : a thin layer of the cutis, with
* Fig. 105. Diagrama or the production of the laminnlcil epitbclisl opsulesj from Boki-
IN THX LYMPHATIC QLANDS. 688
its covering of dark epidermis, extended over the cancer and was slightly
raised by it. The epithelial shape and texture of the cancer-cells were
well marked, bnt most of them contained melanotic matter ; in some, a
quantity of brownish molecular matter was either diffused or collected
about the nucleus or its place ; in some, with similar molecular matter,
there were two, three, or more brown corpuscles, from the size of mere
molecules to that of blood-cells. Materials like those within the epithe-
lial cells existed, also more abundantly as an intercellular substance.
Cells like cylindriform epithelium-cells may also be mingled with the
more usual form. I have seen this in a case of large ^^ cauliflower-
excrescence" of the uterus, in the very substance of which the cylindriform
cells were found.
Bidder describes a similar occurrence in a cancer of the stomach''' and
duodenum ; and Bokitansky,t in the same parts.
I belieye, also, that cases may be found in which the cancer-colls, or
part of them, have characters intermediate, or transitional, between those
of the epithelial and of the scirrhous or medullary diseases. I have men-
tioned the existence of the large free nuclei (p. 579), and the full plump
cells in the capsules (p. 581) in epithelial cancers; and I believe that I
have seen cancers with all their cells of intermediate shape. But the
point is very difficult to determine. Young epithelial-cells are less flat-
tened and scale-like, and have larger and clearer nuclei, than those of
completed formation : in these characters they approach to the appear-
ance of the other cancer-cells; and if, in a quickly-growing mass, they
occur alone, they may produce a fallacious appearance of an intermediate
form of cancer. Moreover, two kinds of cancer may be mingled in one
mass. Lebert and Hannover have satisfied themselves of this; and such
a specimen as they describe may have deceived me. As yet, therefore,
X can have only a belief in the existence of such intermediate forms.
The foregoing description has been drawn, almost exclusively, from
cases of epithelial cancer in integumental parts, and the varieties which
it may present in different localities are so slight and inconstant that such
references as I have already made to them may suffice. But certain
examples of the disease, in other than integumental parts, need separate
description.
The Ltmphatic Glands, in anatomical relation with the primary seat
of an epithelial cancer, usually become similarly cancerous in the progress
of the disease ; and, I think, sooner or later in that progress, in direct
proportion to its own rapidity ; following in this, the same rate as in other
cancers. From the glands nearest to the primary seat, the disease gra-
dually extends towards the trunk, yet seldom reaches far. I have known
the whole line of cervical glands affected in epithelial cancer of the
• MaUer's ArchW, 1852, p. 178. t Uebcr den Zottenkrebs, pp. 11, 18.
584 EPITHELIAL CANCER
tongue ; and the lumbar glands may become diseased with the penis or
scrotum ; but much more often, the proximate cluster of glands ilo&e
becomes cancerous, and those more distant are swollen and saccolent, bat
contain no cancerous matter. This, however, must not be taken to imply
a continuous extension of the disease from the primary seat to the glands;
for large intervals of apparently healthy tissues often interrene. I hare
seen, with epithelial cancer of the back of the hand, the lymphatic gland
near the bend of the elbow similarly cancerous throughout ; but the whole
forearm was healthy.
Last summer I amputated an old man's hand with a similar cancer;
and I have lately seen him with all his axillary glands diseased, but witk
no sign of cancerous lymphatics or other disease in the arm.*
In some cases the diseased glands appear in a large cluster, forming
one lobed mass ; in others, a chain of small glands is felt, such as one
might not suppose to be cancerous, except for their hardness. The can-
cerous elements in the glands resemble those in the primary disease;
indeed, I have found even slight modifications of general character in the
one, exactly repeated in the other.f They are inserted among the natu-
ral structures of the gland. At first, I think, they usually appear in
circumscribed masses, occupying only a certain part of the gland ; bat
these, gradually increasing, at length exclude, or lead to the removal o^
the whole of the original tissues.
The diseased glands are enlarged, hardened, smooth-surfaced, and nso-
ally retain their natural connexion with the surrounding tissues. On
section, part or the whole of the gland presents the same appearance as
a section of primary epithelial cancer; and, generally, the opaque-white
crumbling substance, like scrapings from macerated epidermis, is abmh
dant. One can remove masses of it, and leave only the capsule of the
gland, or some remains of gland-substance that bounded the spaces that
it filled.
Glands thus diseased are not unfrequently the seats of acute inflamma-
tion, in which, with fatty degeneration of the cancer-cells, suppuration
may ensue : they may discharge the pus, as from a common bubo, and
may continue many days thus suppurating. But the end of this is, that
large and deep cancerous ulcers, such as are already described, form in
• Such cases do not prove — they only make it very probable — that there was no canceroos
affection of the lymphatic vessels between the primary disease and the glamls. Suck conti-
nuous disease has been traced from scirrhous cancers of the breast to the axillary ghinds; and
I once found epithelial cancer-cells in the dental canal, when primary disease existed in the
gum and alveolar part of the jaw, and secondary disease in a submaxillary lymphatic gland.
t In one case of epithelial cancer of the tongue, and in another of the larynx, I found
the lymphatic glands affected with what, according to both general and microscopic charac-
ters, could only be regarded as firm medullary cancer. It is possible that, in these casef,
the primary disease was of mixed kinds — medullary and epithelial : just as there are exam*
pies of mixed cartilaginous and medullary tumors, in which only the medullary disease is
repeated in the lymphatic glands (see p. 444). But I found no evidence of this mixture of
diseases in the primary growth ; and I think it equally possible that the cases may be compar-
od with the rare instances of secondary medullary, associated with primary scirrhous, cancer.
IN THB LUNGS. 685
them and the adjacent tissues, and the progress of these is often more
serious than that of the primary disease.
I have seen one example of primary epithelial cancer in lymphatic
glands, which I will relate, both for its own interest, and because it
illustrated many of the foregoing statements. The patient, who was in
St. Bartholomew's Hospital last summer, was a sweep, 48 years old : his
skin was dusky and dry, and many hair-follicles were enlarged by their
accumulated contents; but he had no appearance of cancer, or wart of
any kind, on the scrotum or p^nis : yet his inguinal glands were diseased
just as they commonly are in the later stages of scrotal soot-cancer. On
the right side, OTer the saphenous opening, a cluster of glands formed a
round tuberous mass, more than an inch in diameter. It felt very jGrm,
heavy, ill-defined, and as if deep-set. Over its most prominent part the
Ain was adherent, and ulcerated, and a soft dark growth protruded
through it. Above this mass were three glands, enlarged, but not hard-
ened. On the left side, below the crural arch, one gland was enlarged
to a diameter of half an inch, and hard ; and four others felt similarly
but less diseased. All these were movable under the skin.
This disease had been observed in progress for fifteen weeks, having
begun in the right groin as a hard lump under the skin, like those which
were now in the left groin, and which had commenced to enlarge somewhat
later. The ulceration in the right groin had existed for a week.
I removed all the glands that seemed diseased. The chief mass, from
the right side, appeared, on section, lobed, soft, grayish, mottled with
pink and livid tints. The same changes, but with increased firmness^
were seen in the largest gland from the left side; and the material
pressed from both these (a turbid, grumous, and not creamy, substance)
contained abundant epithelial cancer-cells. The other glands were not
evidently cancerous ; but, during the healing of the operation on the right
side, a gland, which I had thought it unnecessary to remove, enlarged and
became hard ; it was destroyed with chloride of zinc, and then the wounds
healed soundly.
The Epithelial Cancer of the Lungs, which I referred to (p. 564) as
having once seen, occurred in an old man whose penis was amputated eigh-
teen months before death. The disease soon returned in the inguinal
glands and I received these and the lungs for examination. The other
organs were reported healthy.
A cluster of three or four glands were compressed in a large mass, of
which a part protruded through an ulcerated opening in the skin. On
section, nearly the whole of the gland-substance appeared replaced by
the peculiar and oft-mentioned whitish, half-dry, friable substance, with
grayish mottlings and streaked with bloodvessels. In this substance all
the structures of epithelial cancer, with abundant laminated capsules,
were perfectly dbtinct ; they might have been taken as types.
586 EPITHELIAL CAKCBB
In the lungs there were about twenty masses of similar cancerous sob-
stance : and of one large mass, at the root of the right long, I could not
be sore whether it were in the lung itself or in a cluster of bronckial
glands. They were nearly all spherical, or flattened under and in the
pleura, and measured from ^ of an inch to nearly 3 inches in diameter.
Their substance was opaque-white, marbled with pale yellow and pink,
intersected by lines of gray and black (belonging apparently to the involTed
interlobular tissue of the lungs,) and marked with bloodyessels. Tbey
were compact, but brittle and crumbling under pressure : seyeral of the
largest were softer and more friable at their centres than elsewhere, ind
the largest three had great central cavities, filled with softened cancerov
matter and pus : they might hare been called '^ cancerous vomics ;" but
they were completely bounded by layers of cancer, rough and knotted
on their inner surfaces, and had no communication with air-tubes. Froa
one mass an outgrowth projected into, and had grown within, a bronehiil
tube ; from another a similar growth extended into a pulmonary arteiy.
The crumbling, brittle texture of these masses, and the absence of
creamy ^' juice " in eren the softest parts, might have sufficed, I believe^
to declare that these were not masses of scirrhous or medullary canctf :
but the microscopic examination left no doubt. Their minute structures
accorded exactly with those in the inguinal glands : not a character of
the epithelial cancers was wanting. "*"
Epithelial Cancer in the Heart is illustrated in the Museum of St
Bartholomew's.t A man, 58 years old, had a granulated and warty
epithelial cancer, which covered the anterior and inferior third of his eye,
and was firmly combined with the conjunctiva and parts of the sclerotic*
and cornea. Mr. Wormald removed the eyeball with all the disease.
Two years afterwards, the man died with a large tumor over the parotid
gland ; and a mass of cancer, about an inch and a half in diameter, was
imbedded in the substance of the apex of the right ventricle and septum
of the heart. The mass is soft and broken at its centre, and has the mi-
croscopic structures of epithelial cancer.
In the Uterus, and the adjacent part of the Vagina, the epithelial
cancer may be found with ordinary characters, such as were described at
the beginning of the lecture ; but its more remarkable appearance is in
the form of the " Cauliflower-Excrescence." Only a part, however, of
the cases to which this name has been ascribed have been epithelial can-
cers : of the rest, some were medullary cancers, and some, perhaps,
simple non-cancerous, warty, or papillary growths.
My own observations of this disease have only sufficed to confirm
• Portions of the lungs and of the inguinal glands, in this and in the last-described ca^e,
are in the Museum of St. Bartholomew's.
t Series xii. 60. In the Catalogue the disease is described as medullary cancer; bot I
have recently examined microscopically both it and the primary growth (Series ix. So. IT).
and they are certainly epithelial cancers.
OF THE UTBBUS. 687
(wherever I could test them) those far more completely made by Virchow,*
whose results, approved by Lebcrt, and consistent with the best earlier
records, I shall therefore quote : — '^ One must distinguish three different
papillary tumors at the os uteri — the simple, such as Frerichsf and Le-
bert^ have seen ; the cancroid ; and the cancerous," — [t. e. the epithe-
lial cancerous and the medullary cancerous] : — the first two forms together
constitute the cauliflower growth. This begins as a simple papillary
tmnor, and at a later period passes into cancroid [epithelial cancer]. At
first one sees only on the surface papillary or villous growths, which con-
BBt of very thick layers of peripheral flat, and interior cylindrical, epi-
thelial cells, and a very fine interior cylinder formed of an extremely
little connective tissue with large vessels. The outer layer contains cells
cf all sizes and stages of development ; some of them forming great
parent-Btmctures with endogenous corpuscles. The vessels are, for
the most part, colossal very thin-walled capillaries, which form either
simple loops at the apices of the villi, between the epithelial layers, or
towards the surface develope new loops in constantly increasing number,
or, lastly, present a reticulate branching. At the beginning of the dis-
ease, the villi are simple and close pressed, so that the surface appears
only granulated, as Clarke describes it : it becomes cauliflower-like by
the branching of the papillse, which at last grow out to fringes an inch
bng, and may present almost the appearance of an hydatid mole.
^^ After the process has existed for some time on the surface, the can-
croid alveoli begin to form deep between the layers of the muscular and
the connective tissues of the organ. In the early cases I saw only cavi-
ties simply filled with epithelial structures ; but in Eiwisch's case there
were alveoli, on whose walls new, papillary, branching growths were
seated — a kind of proliferous arborescent formation."
It will be evident, from this description, that the cauliflower excre-
scence, in the two conditions distinguished by Virchow, illustrates the
usual history of the most exuberant epithelial cancers (p. 567) : it might
be taken as the principal example of the group. That which he calls
the "simple papillary tumor" is an excessive papillary outgrowth of
epithelial cancer ; the later stage of the same, when it ^^ passes into can-
croid," is the usual extension of such a cancer into deeper parts, — a con-
tinuous growth of the same thing in a new direction. For the papillary
structures, composed^ as Virchow says, of epithelial cells with blood-
ressels and a very little connective tissue, are the essential characters of
the epithelial cancerous outgrowths ; and I believe that the same compo-
sition has never been seen in any papillary or warty growths, that did not,
if time were allowed, proceed to the formation of epithelial structures in
the deeper parts, and thence through the usual progress of malignant
disease.
• WOnburg Verhandl. 1850, R i. 109. They were chiefly made in the cases described
by Mayer in the VerhandL der Gesellsch. fur GeburtshOlfe in Berlin, 1851, p. 111.
t Jenaifche Annalen, p. 7. X Abhandlungen, p. 57^ 150.
588 RODENT ULCBR8.
Before entering on the pathology of epithelial cancers it will be useful
to refer briefly to the morbid anatomy of the diseases with which they
have most affinity, and from which it is most necessary to distingoidi
them, — at least, as clearly as we can. These are, on the one side, the
scirrhous and medullary cancers ; and, on the other, certain rodent ulcen
and warty growths of scars.*
The descriptions in former lectures of the scirrhous and medolUrj
cancers of the skin and subcutaneous tissue may suffice for the distinction
from them (compare pp. 503, 504, 547).
The Rodent Ulcer is the disease which has been described under
various names ; such as cancerous ulcer of the face, cancroid ulcer,
ulcere rongeant, ulcere chancreux du visage, der flache Krebs, mooBartige
Parasit, ulcus exedens, noli me tangere. In its earliest appearance, on
its most frequent seat, it has been called cancerous tubercle of the
face. It has been confounded by many with different forms of cancer;
yet it is distinct from them in structure as well as in history, and had
better be described by some name which may not add to the yearly in-
creasing confusion that arises from the use of terms expressing likenen
to cancer.
Sir B. C. Brodie thus describes the most frequent characters of the
disease if — " A man has a soft tubercle upon the face, covered by a
smoQth skin. He may call it a wart, but it is quite a different thing.
On cutting into it you find it consists of a brown solid substance, not
very highly organized. A tumor of this kind may remain on the face
unaltered for years, and then, when the patient gets old, it may begin to
ulcerate. The ulcer spreads, slowly but constantly, and if it be left
alone, it may destroy the whole of the cheek, the bones of the face, and
ultimately the patient's life ; but it may take some years to run this
course. So far these tumors in the face, and these ulcers, are to be con-
sidered as malignant. Nevertheless, they are not like fungus hsematodes
or cancer ; and for this reason, that the disease is entirely local. It
does not affect the lymphatic glands, nor do similar tumors appear in
other parts of the body."
The constantly progressive ulceration is a character in which this dis-
ease resembles cancer, especially epithelial cancer. The likeness in this
respect may indicate some important affinity between them ; but the dif-
ferences between them are greater ; for not only is the rodent ulcer
usually unlike that of any cancer in its aspect, rate, and mode of pro-
gress, but the tissues bounding it, and forming its base and waUs, never
* The whole of this subject is admirably illustrated by Mr. Cemslt Hawkins, in papers
in the Medico-Chir. Trans, vols. xix. and xxi., and in the Medical Gazette, toI*. xxviii
xxix. Indeed, I can add nothing to his account, except such conclusions as are dt-
rived from microscopic examinations of the diseases. One of Mr. Hawkins's lectures relates
to cheloid growths ; but to these it seems unnecessary to refer ; if they could be confounded
with any form of cancer, it would be with scirrhous cancer of the skin.
t In hit Lectures on Pathology and Surgery, p. 333.
GANGER OF SGAB8. 589
ontain any epithelial or other cancerous structure ; they are infiltrated
rith only such structures as may be found in the walls of common
ihronic ulcers.
:* The most usual characters of the rodent ulcer, whether on the cheek,
lie eyelids, upper lip, nose, scalp, vulva, or any other part, are as fol-
ows:* — It is of irregular shape, but generally tends towards oval or
nrcular. The base, however deeply and unequally excavated, is usually,
11 most parts, not warty or nodular, or even plainly granulated ; in con-
trast with cancerous ulcers, one may especially observe this absence, or
leas amount of up-growth. It is, also, comparatively dry and glossy,
yielding, for its extent, very little ichor or other discharge, and has com-
monly a dull reddish-yellow tint. Its border is slightly, if at all elevated,
it is not commonly or much either everted or undermined, but is smoothly
nmnded or lowly tuberculated. The immediately adjacent skin appears
quite healthy. The base and border alike feel tough and hard, as if bounded
^ a layer of indurated tissue about a line in thickness. This layer does
not much increase in thickness as the ulcer extends; and herein is
mother chief contrast with cancerous ulceration : in the progress of the
rodent ulcer we see mere destruction, in the cancerous wc see destruction
irith coincident, and usually more than commensurate, growth.
The indurated substance at the base and borders of the ulcer appears,
on section, very firm, pale, grayish, uniform or obscurely fibrous ; little
fiuid of any kind can be pressed from it. It is composed of the same
elementary structures as common granulations are, and these, in the
deeper layers, are inserted among the tissues on which the ulcer rests.
I have examined very carefully six of these ulcers, removed by excision,
and have never seen in or near them a structure resetabling those of epi-
thelial or any other form of cancer. Lebert*s observations, I believe, fully
coincide with mine ; though he classes the disease with epithelial cancers,
vnder the general name of Cancroid. Mr. Joseph Hutchinson, also,
has made several examinations of pieces cut, during life, from the margins
of rodent ulcers, and always with the same result ; they never contained
structures resembling those of epithelial or any other cancer.
Thus the anatomical distinctions between this disease and cancer is
evident, and they are equally difierent in pathology ; the rodent ulcer, so
far as it has yet been observed, is never attended by similar disease in the
lymphatics or other part ; and if completely removed or destroyed it does
not recur.
The Warty Growths on Scars (Cancers of Cicatrices) are usually well-
marked papillary epithelial cancers, which grow in the place of scars, re-
• The parts enumerated were the seats of disease in the cases from which I have drawn
myedescription, and in which it is, I believe, most frequent ; but it is not confined to them.
Lebert refers to cases of it, in his account of the cancroid of the uterus, and suggests (what
is highly probable) that the simple chronic, or perforating, ulcer of the stomach is a disease
of iba same nature.
690 OANOBR OF SOARS.
maining after injuries or common ulcers. Mr. Hawkins,* who has given
a Tery full account of their general characters and progress, describes
cases in the scars of burns, gunshot wounds, floggings, and ulcers. All
that I have seen were on the lower extremities, and connected with scan
after repeated injuries.t
The description already given of the warty epithelial cancers may
suffice for these. They usually exemplify very well the wide-spread
growth and cancerous change in the papilloD ; the enlargement, at first
probably simple, and afterwards with cancerous formation, in the papillc
of the adjacent skin ; the deep extension of the disease to the periosteum,
and thence onwards, even to the complete penetration of the bones and
other subjacent tissues ; and, at a late period, the cancerous disease of
the lymphatic glands. But it is important to be aware that this disease
may be closely imitated by warty growths and ulcers, in and about which
no cancerous matter can be found. I examined very carefully such aa
ulcer with prominent growths on the front of a man's leg. It was seated
in the middle third of the leg, in the place of a large old scar after a
scald, and the greater part of the ulcer presented high, lobed, and nodi-
lated hard granulations. No one doubted, before the amputation, thai
the disease was the usual form of cancer ensuing in these conditions ; yet
no cancer structure could be found ; in whichever part I examined, I
could find only inflammatory products, and such corpuscles as compose
ill-developed or degenerate granulations upon common ulcers.
I think some of the diversities of opinion respecting the nature of
these warty growths and ulcers may be due to the want of distinction
between those which are, and those which are not, epithelial cancers. To
the naked eye and during life the two diseases may be very much alike;
but the difierence in their respective minute structures would indicate
essential difference of nature : certainly, in the pathology of epithelial
cancer, caution is necessary in reckoning any of these cases that are
without microscopic examination.
I would add, that I have no doubt the epithelial growth, in some cases,
proceeds from the periosteum or other subcutaneous tissues, and thence
extends into and through the skin. I have seen the growth protruding
through an ulcerated aperture in the scar, just as any deep-seated tumor
might. Such cases justify Mr. Stanley's description of the disease as
one, primarily, of the periosteum.
* Medical Gazette, vol. xxviii. 872 ; and Med.-CUir. Trans., xix. See, also, the Dublin
Quarterly Journal, 1850-51.
t They are amply illustrated in the Museum of St, Bartliolomew^s, Ser. i. and Ser. iixr.
40. Several cases are described by Mr. Stanley (Treatise on Diseases of the Bones, p. 3d0).
EPITHELIAL CANCER — INFLUENCE OF SEX. 591
LECTURE XXXII.
EPITHELIAL CANCER.
PART U.— PATHOLOGY.
Among all the cancers, the epithelial present the general or constitu-
tional features of malignant disease in the least intense form. They
commeni^e at the latest average period of life ; they appear to be most
dependent upon local conditions ; they are least prone to multiplication
in internal organs ; they are associated with the least evident diathesis or
cachexia. And yet I believe that, in a large survey of them, none of the
features of malignant disease, as exemplified in the scirrhous and medul-
lary cancers, will be found wanting : the difference is one of degree, not
of kind.
(a) A large majority of the cases of epithelial cancers occur in males.
In 105 cases, affecting parts common to both sexes, 86 were in men and
19 in women. In the cases affecting the sexual organs themselves, I think
the proportion is nearly equal ; unless we reckon the scrotal soot-cancerSy
which, for obvious reasons, we should more properly exclude.
(b) A few cases are on record, transmitted from book to book, in which
what were probably epithelial cancers occurred before adult life. Sir
James Earle saw a scrotal soot-cancer in a child eight years old ;* so did
Mr. Wadd ;t and M. LebertJ examined a " cancroid** growth at the \'ulva
in a child 3^ years old, in whom it was almost congenital. But cases
such as these cannot be taken into our estimate of the influence of age
in determining the access of the disease. In the following table, I have
included no cases that were recorded merely or chiefly on accoimt of the
patients' ages :§
Ag«. No. of cftMi.
20 to 30 . . . . . . 9
30 to 40 . . . . . .22
40 to 50 . . . . . . 40
50 to CO . . . . . .32
60 to 70 . . . . . . 30
70 to 80 . . . . . .10
143
• Pott*a Works, by Earle, iii. p. 178. t Curling on the Diseases of the Testis, p. 528.
^ TraM Pratique, p. 676. Hannover (Das Epithelioma, p. 104) quotes from Frerichs a
caje in which the disease extended from the ear through the petrous bone in a male 10 years old.
S The table includes cases from Lebert, Hannover, and others. But I have omitted, both
[rom it and from the preceding one, Lebert's cases of " cancroid" of the face. Tliey were
examples of rodent ulcers, and their contrast with epithelial cancers (of the lip, for example)
ii well shown, in that the average age for their coming under operation is 17 years later,
and the proportionate frequencies in the two sexes is reversed. The ages assigned in the
above tmble are, with few exceptions, those at which the disease was first observed by tht
patimU.
592 BPITHBLIAL OANOKR.
If now, as in the last two lectures (pages 513, 551), we calculate, from
this table, the frequency of epithelial cancer in proportion to the number
of persons living at each of the successive periods, it may be represented
by the following numbers (100 being, as before, taken to express the fre-
quency between 40 and 50) : —
20 to 30 years 12
30 to 40 " 41
40 to 60 " 100
60 to 60 « 110
60 to 70 « 163
70 to 80 " . Ill
We may probably deduce from this calculation, that the conditions
favorable to the production of epithelial cancers regularly increase widi
the increase of age ; for, the apparent diminution after 70 may be ret-
sonably ascribed to the comparatively small proportion of persons beyond
that age who are received into hospitals, or who are under such surgicil
treatment as to have their cases recorded.
The proportions expressed by the foregoing general tables are nearij
true for the epithelial cancers of each part most liable to be affected : the
only notable peculiarities, I believe, are, that the mean age of its occlI^
rence is lowest in the sexual organs, and highest in the integuments of
the head, face, eyelids, and upper extremities.
{c) An hereditary disposition to soot-cancer has been several tines
observed: as, by Mr. Earle,* in a grandfather, father, and two sons; by
Mr. Hawkins,t in a father and son ; by Mr. Cusack,J in a mother and
son ; by myself (twice) in two brothers. But all the persons here referred
to were engaged in the same trade, and their exposure to the same ex-
citing or predisposing cause of the disease diminishes the value of the
facts as indications of hereditary predisposition. I have no certain record
of other epithelial cancers occurring in many members of the same family;
but I have found some significant facts indicating a disposition to epithe-
lial cancer, in members of those families in which other members have
had scirrhous or medullary cancers.
Among 160 instances of cancer, in most of which the point was in-
quired into, though none were collected for the sake of it, these cases were
found : — (1) A man had medullary cancer of a toe : his father had a cancer
of the lip. (2) A woman had repeated epithelial cancers of the labia:
her sister, her father's sister, and her mother's brother's daughter, had
cancer of the breast. (3) A man had epithelial cancer of the lip, whose
grandmother had cancer of the breast. (4) A gentleman had epithelial
cancer of the interior of the cheek : his aunt died with cancer of the
breast. (5) A woman had medullary cancer of the breast : her mother
had cancer of the uterus, and her uncle cancer of the face. (6) A woman
had scirrhous cancer of the breast, whose mother's uncle had cancer of
* Med. Chir. Trans., zii. 306. f Medical Gazette, xxi. '842.
{ Quoted by Mt. CutVini^ ^Ou \>\se«i«e% ol ^«T««v\v,^. Wli]^
HEBBDITABT DISPOSITION. 698
the lip. (7) Of another woman with similar cancer, one cousin had can-
cer of the lip, another cousin cancer of the uterus. (8) A third woman
kad scirrhous cancer of the breast, whose grandfather had cancer of the
lip.*
The proportion of these cases (only i^ of the whole number) may
seem too small to be even suggestive ; yet it is too large to be referred
to chance. Let it be contrasted with these facts: — (1) I have found that
among 116 patientsf with cancer, only one was aware of any number of
the same family having had a simple tumor. This was a woman with
scirrhous cancer of the breast, from whose sister a myeloid tumor of the
breast had been removed. (2) Among 77 patients with non-cancerous
tumors, 10 were aware of near relations having had similar diseases: but
among the same 77, the only cases of family connexion with cancers were
the following: — (a) The cases of recurring and disorderly-growing mam-
mary tumor related at page 474; {b) the case of anomalous cartilaginous
tumors at page 431 ; {c) that of the same woman whose case was just
mentioned as one of myeloid tumor of the breast : five years after its
removal, she and her sister were at the same time in St. Bartholomew's
with scirrhous breasts ; {d) that of a lad with mixed cartilaginous and
^andtdar tumor over his parotid gland, whose grandmother had cancer
o£ the breast. Now of these cases the first two must be regarded, I
believe, as instances of a cancerous disposition, modified and gradually
eeasing in its transmission from parent to offspring (see page 474, &c.) ;
the third is a very anomalous one, exemplifying the formation of a most
rare tumor in the breast, not long before it became cancerous ; the fourth
alone is an instance of an ordinary simple or innocent tumor growing in
one who had a cancerous relation.
I have referred to these cases, not to suggest that when cancer has
occurred in one or more members of a family, the rest are peculiarly
anlikely to have innocent tumors, but to show, by contrast, that the pro-
portion of cases in which epithelial and other cancers occur in the same
fiunily is, relatively, considerable. For if that proportion were the result
of chance-coincidences or errors in observation, an equal, or nearly equal,
proportion of coincidences should have appeared in the opposite set of
cases.- But the contrast between the two sets of cases is remarkable;
and I believe the facts may be justly regarded as evidence for the close
affinity between epithelial and other cancers, and as an illustration of the
* Dr. Warren mentions this : — A grandfather died with a cancer of the lip. His son and
two dmnghters died with cancer of the breast. One of his grandsons and one of his grand-
daogbtsn had also cancer of the breast (On Tumors, p. 281). It may be objected, by some.
that the cancers of the lip here referred to were not epithelial I assume that they were,
because of the exceeding rarity of any other kind in the lip : indeed, I have not yet seen one,
or s complete record of one, in which the microscope did not find the epithelial structures.
f These were part of the 160 mentioned above ; but I have here reckoned only the cases
recorded by myself, because it is probable that, even if, among the others, any instances had
oeouired of innocent and malignant tumors in the same family, they would not have been
mentioiied.
88
594 EPITHELIAL OANOBR.
modification which the cancerous and other diatheses may midergo in
their hereditary transmission.
(d) Among 34 patients with epithelial cancers, 19 were aware of injury
or previous morbid condition in the affected part ; — a much larger pro-
portion than is found among patients laboring under tumors of any other
kind, except melanoid cancers of the skin.
In certain cases, injury by violence appears as the exciting cause. Bat
the histories of epithelial cancers differ from those of others in that the
kind of injury which is most effective in their production is such as k
often inflicted — ^frequent blows or slight wounds on the same part ; hurts
of scars and other seats of old injury. It is as if it were necessary thit
the part should be considerably changed in structure, before it is appro-
priate for a cancerous growth.
It agrees with this that, in the majority of cases, patients assign, as the
cause of the disease, not injury, or not it alone, but some former disease,
especially such as arises from long-continued irritation of a part. Thu
epithelial cancers arise sometimes in old ulcers, as on the legs, or, as I
have known, in perineal urinary fistulae ; sometimes, in those of more
rapid progress, as I once saw in a case of necrosis of the hard palate,
and once in a case of necrosis of the angle of the lower jaw, and, as Fre-
richs describes, in an ulceration of the internal ear following scarlet feTer.
The majority of the epithelial cancers of the prepuce and glans occur in
those who are the subjects of congenital phymosis, and in whom we nsj
assume the frequent irritation of the part by decompoded secretions. In
some rare cases, a mole or pigmentary naevus becomes the seat of the
disease. But, among all the things referred to by patients, none are »
frequently named as "warts."
The affections thus named are not usually such as are commonly
called warts. They are not usually like the warts (Verrucae, or Condy-
lomata elevata) that grow on the genital organs during gonorrhQ&al or
other similar irritation ; nor like such warts (Verruca vulgares) as are
common on the hands of young people before puberty ; nor like the con-
dylomata (G. lata) of syphilis. S^uch papillary growths as these may, I
believe, precede epithelial cancer ; but I think they rarely do so. The
general condition of the "wart** is, I think, that a small portion of the
cutis is slightly indurated ; its papillae are, generaUy, in some measure
enlarged ; and it is covered with a darkish dry crust, or with a scab, or,
if the part be very moist, with a soft layer of detached scales.* The
induration of the cutis, and the predominance of the crust or other cov^-
ing (which apparently constitutes more of the disease than either the
induration or the papillae), mark the chief differences between this dis-
ease and any of the "warts" just referred to. The induration, which
patients often ascribe as " a little hard knot," is usually attended with
* Sucb as these are well described by Schub (Pseudoplasmen, p. 46), under the title
'' barky warts." Witb the same intimation of likeness, Dr. Warren (On Tumors, p. 27) cmlled
the disease *' Lepoides.^^
INFLUKNOB OF INJUBT AND PRBVIOUS DISEA8B. 695
deyation, bat sometimes with contraction and depression of the piece of
cutis. The crust consists, for the most part, of epidermal scales held x
together by dried secretion, or, in its deepest layers, forming whitish
friable substance, and fitting between the papillae. It is easily detached
and quickly remoYcd ; and, when it is removed, the subjacent cutis does
not usually appear raw or bleeding, but is tender, florid, and as if covered
with a very thin glossy layer of epidermis. When a moister yellow scab
oovers the induration, the surface beneath it is usually more inflamed
ind excoriated, and the papillae are more enlarged.
Such incrusted warts 'as these are very common, especially on- the
fi^es of old persons : the large majority of them lead to no further trouble ;
yet some become the seats of epithelial cancers, and some of rodent
ulcers. A similar affection often precedes the epithelial cancer of the
lower lip. Some slight violence often applied, such as that of a short
pipe habitually supported by the lip, or the frequent slight rending of
the surface of a dry scaly lip, or one much exposed to weather, leads
to a ^^ little crack:" this scabs over, and after repeated removals and
renewals of the scab, there is a '^ little hard lump" or '^ a sort of wart,"
with a head or crust. And such a wart might be as often innocuous on
the lip as on the face, if it were not that the lip is in the unhappy singu-
larity of being within easy reach, at once, of the fingers, the teeth, the
tongue, and the other lip ; so that when it is as yet but slightly diseased,
it is never left at rest.
A similar drily scaled or incrusted warty change of the cutis often, I
believe, precedes the chimney-sweep's cancer ; and I suspect that the
true influence of the soot in this disease is not that its continued contact
determines the growth of cancers, but (at least in part) that it produces
a state of skin which provides an apt locality for epithelial cancer in
persons of cancerous diathesis. How it does this I cannot imagine : but
this is only one of many things unexplained in this strange disease ; for
the whole of the peculiarities of the chimney-sweep's cancer, — its depen-
dence on soot, while coal-dust is wholly inoperative (for the disease is
unknown among colliers) ; its comparative frequency in England, especi-
ally in the large towns, while in other countries where soot is abundant
it is hardly seen ; its selection of the scrotum for its most frequent seat,
— all these, and many like facts in its history, appear completely inex-
plicable. Still, it is certain that scaly or incrusted small warts, such as
I have been describing, are very common in chimney-sweeps. In many
of them, even when they are thoroughly cleaned, the whole skin is dry,
harsh, and dusky;, and before operation for the removal of scrotal cancers
in them, it is a common question whether one or more warts or scaly
patches near the chief disease should be removed with it. Nor are such
warts confined to the scrotum; they may exist on every part of the trunk
and limbs ; and I have seen sweeps so thick-set with them, that a hun-
dred or more might have been counted.
596 SPITHBLIAL OANCBR.
Such are some of the numerous morbid states, one or other of which
* may, in the majority of cases, be assigned as predisposing a part to
become the seat of epithelial cancer. Expressions are sometimes used,
implying that the part does not become the seat of a new morbid stnio-
turo, but that its mode of action is changed, or that the change is only
due to the extension and deepening of a common epidermoid or wartj
growth. The truer view, however, may be expressed by saying that the
part, whatever were its previous state, becomes the seat of epithelial
cancer, the structures of which, as of a new disease, are inserted among
the original or previous morbid textures of the part. This evidently
happens when the cancer appears in parts previously healthy, or in the
deep-seated tissues, or in the walls of ulcers, or in a pigmentary nsevns;
for, in these cases, no morbid structures of the epithelial cancer existed
previous to its access. There is more appearance of similarity and cod-
tinuity of disease between the epithelial cancers and the warty growthB
by which they are sometimes preceded : for here both the earlier and the
later disease may have, in common, an accumulation of epidermoid cells
and an enlargement o^ papillae. Yet the warts, whether incrusted or
others, in which the epidermoid structures are only superficial, should
also, I think, be regarded as only predisposing conditions of epithelial cao-
cer ; as diseased parts, not cancerous, though peculiarly apt to become die
seats of this form of cancer. For the great majority of these are statioih
ary aflfectious, or may disappear, or be cured even in cancerous persons;
they are comparatively few in which, after a certain duration as simple
warts, the cancerous disease is manifested. And the time of this change
in them is often well marked. Nearly all patienta,^-even those who can
assign no date to the beginning of the wart or hardness, or other previous
disease, — can refer exactly to some time of change in it, when it began
to "grow up," or "be sore," or "get bad," discharge or bleed. They
thus mark the time when the cancerous mode of progress was commenced:
and from this time the history of all such cases is nearly uniform— even
remarkably uniform if it be compared with the variety of the histories of
the previous states.
Now, I believe that this change in the life of the warty or other dis-
eased part is always associated with a change in its structure ; and that
whatever were its previous state, its proper tissue, whether papillae or any
others, now become the seat of the formation of epithelial cancer-celb.
It is hardly possible to prove such a change of structure in any single
case, but it is rendered highly probable by this, — that in those warty
structures which w^e remove because experience makes us believe that
they are in progress as epithelial cancers, we find the tissues infiltrated
with the specific cancer-cells : while in those which have been long station-
ary, without extension or outgrowth, without ulceration or ichorous dis-
charge, no such infiltration is found. Certain cases must be excepted
from this statement because of error in diagnosis. I have known rodent
GROWTH AND ULCERATION. 697
doers excised, in the belief that they were epithelial cancers; but I never
saw any growth removed as an epithelial cancer, in which the epider-
moidal cells were placed only on the surface of the vascular tissues ; and
on the other hand, I have never seen such cells in the cutis or papillae of any
incmsted or other wart, in which the cancerous mode of progress was not
yet manifested. The opportunities of examining such warts as observation
ihowB to be most apt to be precursors of epithelial cancer are rare: but
I have examined some on the scrotum, and one on a lower lip. The
last may deserve description.
A healthy-looking farmer, 66 years old, came to me with an indura-
tioD, about two lines wide and half a line thick, at the middle of the
florid margin of his lower lip. The indurated part was slightly sunken,
and covered with a thin yellow scab. This disease had existed two
years, frequently scabbing thickly, then desquamating, never soundly
healing ; yet it had made no progress. I removed it, chiefly because
the patient's father, when 85 years old, had had cancer of the lower lip;
and because, if not already cancerous, this could not but be thought a
place very likely to become so. I found, in the indurated tissue, inflam-
matory products infiltrated among the natural structures of the skin ;
but no appearance of epithelial cancer-cells. The cutis was slightly
thickened ; but there was no evidence of enlargement of papillse, or of
accumulated epidermis : the scab seemed formed chiefly of dried secretion.
I believe that such a description as this would apply to most of the
warts that precede epithelial cancers of the lower lip, and that we may
justly say of them that they are not cancerous, but are such parts as,
in certain persons, are peculiarly apt to be the seats of cancer. Why
only some among them should become cancerous we can no more explain
than we can why, among so many injuries inflicted, so few should be
followed by erysipelas or tetanus ; or why, among so many pigmentary
moles or na^vi as may be found, only few should become the seats of
melanoid cancer ; or, in a yet nearer parallel, why, when a person has
many such moles, the melanoid cancer should appear in only one. In
these varieties of fate, there is nothing unusual in warts, if we regard
them as only predisposed to become cancerous ; but, if we regard them
as the first stage of a cancroid or cancerous disease, such varieties of
progress as they manifest would be without parallel.
(e) The general health of patients with epithelial cancer is usually
good, till it is 'afiected by the consequences of the local disease. No
primary cachexia can be observed preceding the appearance of the
growth ; nor does a secondary cachexia ensue earlier than it probably
would in any disease of equal duration and severity.
When the formation of an epithelial cancer has once commenced, its
natural course is as regularly progressive to the destruction of life, as
that of either a scirrhous or a medullary cancer. Only, the rate, and
some parts of the method, of progress are different.
598 EPITHELIAL CAlfOBB.
The average rate of increase of epithelial cancers is less than of either
of the other kinds. It is not apt to be arrested altogether ; yet it is
sometimes so slow that, in a year, the cancer may gain only a line or
two in any of its dimensions. In other cases, however, and especially
when such a cancer has been violently injured, the progress is mndi
more rapid. I have known three-fomrths of the scrotum covered with
ulcerating soot-cancer, and part of the urethra surrounded by it, in
three months after a laceration received while in apparent health : in
another case, a spheroidal mass of soft epithelial cancer, an inch in
diameter, formed in the substance of the cheek in two months; in
another, a growth more than an inch in diameter formed in ten weeh;
in another, the whole depth of the lower lip, and two-thirds of its
width, were occupied with epithelial cancer in three months after a
blow on a little cancer at its margin ; in another, within twelve months,
the eyelids and a large part of the contents of the orbit were destroyed
by ulceration, and tuberous masses, from one to three-quarters of an
inch in diameter, were formed under the integuments of the brow, the
temple, and the other boundaries of the orbit.
Cases such as these, and they are not rare, may prove the error of
regarding epithelial cancer as a trivial or an inactive disease in compa-
rison with the other forms. Its rate of progress is, like that of scirrhous
cancer, widely various in different cases ; it has its acute and its chronic
instances. Of its modes of growth, and of ulceration, and of the usual
coincidence of these processes, I have spoken fully in the former part
of the lecture (p. 575) ; I will here only add that the ulceration, at
whatever rate, seems constantly progressive. Some portions of the
ulcer may appear, for a time, as if skinning over, or, portions of the dis-
ease may slough away, and the surfaces they leave may partially heal ;
but I do not remember to have seen any process of healing or wasting
so nearly accomplished in an epithelial cancer, as I have described in
some cases of both scirrhous and medullary cancer, in the former
lectures (pp. 519, 558).
The progress of the ulceration, and the coincident deepening of the
growth, are usually attended with great pain, — hot, scalding, and widely
diffusing pain ; 'or with pain like that of neuralgia darting in the course
of nerves. With this, and the constant ichorous discharge from the
ulcer, and the occasional bleedings from ulcerated bloodvessels, the
patient becomes cachectic ; yet probably not sooner than in other diseases
of equal extent, nor in any very characteristic manner.
Primary epithelial cancers are usually single. Two growths may
sometimes appear at once in the same region, as, e. g. on the prepuce
and glans, or on the scrotum ; but even this is rare. In the later pro-
gress of the disease, separate masses of epithelial cancer may be sometimes
found in the tissues, or cancerous warty growths on the surface, around
the primary grovrlVi ot xAci^x. Hfc^Wx^ tlsauiQ appears to intervene
MULTIPLIOITT — SXTBN8I0K. 599
between these secondarj cancers and the primary one : and thej may
be compared with the tubercles so often grouped around a scirrhous
mammary gland.
The lymphatic glands, sooner or later in the progress of the disease,
nsoally become cancerous. I have already (p. 584) described the manner
of their infection. I feel almost disposed to think that epithelial cancer
18 a much worse disease in this country than in France or Denmark,
when I see how far my observations on the affection of the lymphatics
differ from those of Lebert and Hannover. Lebert* says that he has
found the lymphatic glands affected with ^^ cancroid" three times in 81
cases ; and of these 81, 60 were certainly cases of epithelial cancer.
Hannoverf has even less frequently seen them diseased. Now, in 42
cases of epithelial cancer collected in the ordinary course of hospital
and private practice, and including many in the early as well as in the
latest stages of the disease, I have observed the lymphatics cancerous
twenty times. In the greater part of these cases, the characteristic
cancer-structures were found in the glands removed during life or after
death : in the rest, their existence was concluded, with scarcely less cer-
tainty, from the enlargement, with induration, rapid growth, ^jlustering,
and destructive ulceration of the glands. It need not be suspected that
in any of these cases the glands were enlarged merely through " irrita-
tion ;" such a state does, indeed, occur with epithelial as with scirrhous
cancer, but the diagnosis of this from the cancerous enlargement is
seldom, in either case, difficult.
I do not suppose that the proportion cited above expresses the greatest
frequency of epithelial cancer in the lymphatic glands. I believe rather,
that very few cases reach their natural end without infection of the glands.
Even after the primary disease has been wholly removed, and when the
glands at the time of the operation appeared healthy, they are fre-
quently, and often alone, the scats of recurrences of the disease (p. 602).
Sometimes, also, as with scirrhous cancers (p. 504), we find the disease
in the lymphatics greatly preponderating over that in the primary seat.
My observations are scarcely less different from those of Lebert, in
relation to the occurrence of secondary epithelial cancers in internal
organs. In 18 autopsies (some of which, however, were made in fatal
cases of rodent ulcer) he has not once found " cancroid growths'* in any
internal part. In 7 autopsies,^ I have found epithelial cancer once in
the heart, and once in the lungs ; [its appearance in these parts is de-
scribed at p. 586.] Doubtless, the internal organs are more yarely
infected than in any other form of cancer ; but they do not enjoy an
• Traits Pratique, p, 619. 1 1^8 Epithelioma, p. 24.
j; In two of these the disease had not reached its natural end ; for tlie patients died in
consequence of amputation. In another case I found epithelial cancer of the tongue, with
medullary cancer of the cervical glands, and of the lungs; but, as I have already said (p.
584), though no medullary cancer-structures were found in the primary disease, it was impos-
■ible to prove that they bad never existed, for a hirge portion of the tongue bad sloughed
before death.
600 BPITHBLIAL OAVOB&.
absolute immunitj ; the difference between the epithelial and the other
cancers is, in this point again, one of degree, not of kind.
It is a pecnliarity of epithelial cancers, that in nearly all the charac-
teristics of malignant disease — ^whether the propagation to the lympha-
tics or other organs, the extension to deep-seated parts, the recurrence
after removal, or the rate of progress towards death — ^greater differeacei
are noted according to the seat of disease than among the medullary
cancers of different parts. The anatomical characters of the disease
are in all parts essentially the same, but their history, in all the parti-
culars noted above, differs, so as to justify the expression that the disease
is less malignant in some parts than in others. It is, generally, most
malignant in the tongue, the interior of the mouth, and the penis ; least
in the lower extremities and the scrotum ; in general, also, the epithelial
cancers that are deep-seated are more malignant than the superficial
These diversities make it very difficult to assign the average duration
of life in persons with epithelial cancer ; and the difficulty is greatly
increased by the recorded cases being often mixed or confounded with
those of other cancers and of rodent ulcers. I have not been able to
collect more than 30 cases, traced to the end of life. Of these, 12 were
not submitted to operation; in the remaining 18, the diseased parts
were once or more removed, and the operation was^ in none of these
cases fatal. The average duration of life in the former was 38*6 months;
in the latter 39-3 months : the general average of the whole was 39 months.
But, with these cases, I have also those of 8 patients, still living beyond
39 months ; and if these be reckoned with the other 30, they raise the
average to 44 months.
I believe the true average duration of life with epithelial cancer is
higher than 44 months ; for the cases I have collected, being chiefly those
of hospital and other patients, who when first seen, were in a state to
be remedied by treatment, probably contain too small a proportion of
those of longest standing. Probably four years is about the true average.
The following table will show the duration of life in the 38 cases,
and may be compared with those in p. 524 and 561 : the total difference
produced by operations appeared- too slight to make separate tables
necessary : —
Duration of Life. Number of Ga*M.
Less than 6 months 1
Between G and 12 months 1
« 12 " IS « 7
u 18 « 24 " 4
" 24 « 30 « 5
" 3 *' 4 years 3
" 4 « 6 « 3 dead
^ 6 living
** 6 « 8 " 4 dead
1 living
More than 8 years 2 dead
1 living
BS8ULT8 OF OPBRATIOKS. 601
The chief point which this table shows, in contrast with those of other
cancers, is in the proportions of patients living more than four years.
The proportion is here nearly half; while in the cases of scirrhous cancers
it 18 only \^ and in those of medullary cancers only ^^ (<>^9 ^^i^x opera-
tions, i\ and ^.7 respectively). An equal contrast is in the proportions
of those dying within twelve months of the access of the disease : the
proportions being, in the cases of epithelial cancers, less than y'5 ; of
leirrhoiis cancers, nearly \ ; of medullary cancers, nearly \. In both
these respects, however, differences may be noted among the epithelial
cancers of different organs. I have not yet found a case of one in the
tongue surviving more than four years; nor of one in the trunk or limbs
destroying life in less than three years: a majority of those in the lower
lip are fatal within four years, but some few survive that period. The
ige at which the disease commences has no great influence on its dura-
tion. The average duration among 14 patients, in whom it commenced
ftt or below 45 years of age, was 39 months ; that among 17, in whom it
tx>mmenced later, was Mb\ months ; and the general average duration
iras not exceeded in the first list more often than in the second. There
is, therefore, no well-marked correspondence, in this respect, between the
epithelial and the scirrhous cancers. [Compare p. 524.]
A very trivial proloiigation of life would appear, by the cases I have
collected, to be obtained by the removal of epithelial cancers. But I
would not use this result for more than general guidance in practice;
for though I have no doubt that the common opinion of the epithelial
cancers being trivial diseases, in comparison with the scirrhous and me-
dullary, is very incorrect, yet I cannot doubt that, in some cases, perma-
nent recovery, and, in some, a long period of health, follows their removal.
[ have seen a man whose leg was amputated twenty years previously
for epithelial cancer commencing in or beneath a scar, and he was still
irell. A sweep was lately in St. Bartholomew's with a small scrotal cau-
ser, from whom one of the same kind was excised thirty years ago. Of
mother, Mr. Curling* gives a history extending over twenty-two years,
md including five operations. A man from whom Mr. Lawrence removed
i cancer of the lip remained well for nine years, and then the disease
appeared in the lymphatic glands.
Cases such as these must, I believe, be considered very rare. Too
nuch regard to them, and the confusion of the rodent ulcers with the
3pithelial cancers, have led to a common belief that recovery or long life
nay be promised as the consequence of operations. Such a promise, if
generally made, will very seldom prove true ; and yet, as a general rule,
Jie operation is to be advised, whenever the whole of the disease can be
•emoved without great risk of life, or of producing worse deformity than
dready exists.
For (1) though the instances of operations followed by complete reco-
• On Diseased of tho Testis, p. 535.
602 BPITHBLIAL CAHOBE.
very, or by long immunity from the disease, are very rare, yet, in certaii
cases, these results may be hoped for. This is especially the cue, I
think, with the epithelial cancers of the lower extremity, which foUow ii-
jury, and for which amputation is performed ; with the soot-cancers wUd
are not making quick progress ; with the more superficial cancers of thi
lip. On the other side, according to present experience, such lengdMi>
ing of life cannot reasonably be hoped for after operations for the ephb^
lial cancers of the tongue, the gums, or other parts in the interior of tkt
mouth.
(2.) In the majority of cases, and even when very little increase flf
life can be hoped for, the removal of the disease may gtre great confoit
for a time. In general, also, the greater part of the time that intenrcM
between the recovery from the operation and the recurrence of the <i»
ease may be reckoned as so much added to life ; for although we canH
deny a diathesis, or specific constitutional affection, in epithelial canoef%
yet it is by the progress and consequences of the local disease that, b tkt
majority of cases, the time of death is determined ; so that, while \oai
disease is absent, life may be shortening at scarcely more than the ar&>
nary rate. Of course, in applying such a rule as this may snggeit ii
practice, we must except from it certain cases in which the general ketU
is already very deeply affected, or in which the operation would be poi-
lously extensive.
(3.) The extension of the epithelial cancer to the lymphatic glands ii
not an insuperable objection to operations. The disease usuallj ^^
mains long limited to the glands which arc nearest to its primary Mtt >p.
584) ; its complete removal can therefore be usually accompliiihed : i»i
although I can cite no instance of very long survival after opemiioa in-
cluding cancerous glands, yet, on the other side, I can cite none which
would prove that the recurrent disease is quicker or more severe ifw?
such operations, than it is after those of equal extent in which the glani»
are not yet diseased.
(4.) The general rule concerning operations in cases of recurrent epith^
lial cancer may be the same, I think, as for the primary disease. A
second operation is, in general, less hopeful than a first, yet not alwiy*
so ; for although the epithelial, like other cancers, usually make pm<n^«
at an accelerating rate, yet cases are not wanting in which the intep^al^
between successive operations have progressively increased.
I have tabulated 60 cases in which epithelial cancers were removed
with the knife. In 8 the operation (amputation at the thigh) was fiul
or accelerated death ; in 27 the disease recurred ; the remaining 30 tr«
lost sight of, or are still living, and among these are 3 of those 8 patieotf
whom I mentioned (p. 600) as living beyond the average period : in ihe?c
3 the disease has not reappeared; but in 2 of the 8 the recurrent disetse
is still in progress.
Among the 27 cases of recurrence, the secondary disease was in or
RESULTS OF OPBBATIOKS. 608
near the same place eleven times; in the lymphatic glands, eight times;
in both, eight times. The periods of recurrence ranged from one to
twelve months, and were, on the average, six months after the operation.
In 20 of the 27 cases, the disease after recurrence was allowed to run its
eonrse. In the remaining 7 the recurrent cancer was removed, and with
these results : — (1.) Cancer of a labium removed after eight months' dura-
tion, recurred in two months ; it was removed a second time, together with
cancerous glands, and the patient remained well for fourteen months ; then
&tal recurrence ensued. (2.) Cancer of a labium was removed after thirty-,
tax months' duration ; thrice after this the disease reappeared in or near
the same part, and was removed after intervals of twelve, three, and
twent j-four months ; the patient has already survived the last operation
iwenty-eight months; and, though the disease has again recurred, it
makes slow progress. (3.) Cancer of the lip, of forty-eight months'
duration, recurred in the cheek after three operations, with intervals of
six, three, and four months ; and the patient is now dying at a distance
of eight months from the last operation. (4.) A cancer of three months'
duration was removed from the nose ; a new growth appeared near the
tear a month after the operation ; it Was removed with potassafusay and
the patient has remained well for six months. (5.) A cancer of the lip
of four months' duration was removed ; in a month disease reappeared ;
this also was removed, and the patient had no recurrence in the follow-
ing six years. (6.) In a similar case recurrence ensued in two months ;
but the patient remained well for at least twelve months after the second
operation. (7.) A cancer of the scalp was removed after eighteen months'
dmration ; it recurred in six months, and was again removed, and there
was no reappearance of it in the next eighteen months.
These, and similar cases referred to by M. Lebert, are enough to show
that repeated operations may be, in certain instances of epithelial cancer,
folly justified. And perhaps we may gather from them an additional
motive for very free excision of the cancers ; for the excision of a recur-
rent disease, undertaken as a nearly desperate measure, is generally more
free than the first operation was ; and thence, it may be, its occasionally
greater success.
Let me now collect from the facts of this lecture the grounds which
seem to justify the inclusion of this disease under the name of cancer. It
is not unimportant to do so ; for we may be certain that, in this case, the
name of the disease will often guide the further study and the treatment
of it.
I have excluded from the group of epithelial cancers the rodent ulcers,
which M. Lebert includes with them under the name of " cancroid."
The two diseases are so constantly unlike, in both structure and history
(see p. 588), that their separation under difierent titles seems consistent
with the most usual rules of nosology. I have also excluded those papil-
lary and other affections of the skin, in which epidermoid structures are
604 EPITHBLIAL CAKOBR.
\
accumulated only on the surface of the affected part. For, altboogh
these maj sometimes appear like the first stages of certain epithetid
cancers (see pp. 569 and 596), yet the distinction between the two is coi»>
monly well-marked in the history of each case : and, in their respectiTf
anatomical relations, the distinction between a superficial and an inter*
stitial epidermoid structure is very significant ; since the former b&* its
nearest homologue in natural epithclia, the latter in caucerou:» in£iin-
tions.
Thus limiting the diseases to bo included under it, the name «'f fpi-
thelial cancers seems justified by their conformity with the scirrhoL aoj
medullary cancers in these following respects : —
(1.) The interstitial formation of structures like those of epithelinm if
not an imitation of any natural tissue ; it constitutes an heterolopw
structure ; for superficial position is more essential to the type of tft
thelial structures, than any shape of elemental cells or scales i;>.
(2.) Even that delusive appearance of homology, which exists «hit
the structures like those of epithelium are formed in the dermal tiMMH
and therefore near the surface, is lost in nearly all the cases of <1m<p>
seated epithelial cancers, and in all the similar affections of the lymphtsk
glands and internal organs.
(8.) The interstitial formation of cells in epithelial cancer is conform<4
with the characteristic plan of all cancerous infiltrations, and lea«L« to i
similar substitution of new structures in the place of the original tissoc*
of the affected part.
(4.) The intcrstitially-formed cells often deviate very widely from tii<
type of any natural epithelial cell, in shape, in general aspect, in mnh-J
of arrangement, and in endogenous fonnation (p. 579, e. s.). Thv diif
rence between them and any natural elemental structures is, indeed, mwh
greater than that between many medullary and scirrhous cancer-cell* anl
the cells of the organ in which they grow : e. ff. it is sometimes *l\Bcih
to distinguish the cells of a medullary cancer in the liver from thi»*e kA
the liver itself.
(5.) The pathology of epithelial cancers is scarcely less confuna^i
than is their anatomy to the type represented by the scirrhous and nn-Jcr
lary cancers ; for, not only are they prone to incurable ulcerati«ai, aai
to repeated recurrence after removal, but (which is much more chanctc
ristic) they usually lead to the fonnation of structures like them«el\e? in
the lymphatic glands connected with their primary seat, and they Itad
sometimes to similar formations in more distant organs (p. 5iS3, e. ?.».
(G.) In their growth, and in their recurrence, there is no tissue which
the epithelial cancers do not invade and destroy (pp. 571 and 577).
(7.) A peculiar liability to them seems to exist in certain member*
of those families in which scirrhous or medullary cancers also occur {p-
692).
Such are the affinities between the epithelial and (as I would say) iht
other cancers. TViey u,tq «o ii\]L\\ieiQ>]& «.vkd ^ close, that I cannot bot
MELANOID AND OTHBR CANCERS. 605
think we should be guided in the choice of a name by them, rather than
by any other consideration. They are surely more significant of affinity
irith the other cancers, than the contrast between the shapes of the ele-
mental cells is indicative of such difference as should be expressed by a
different generic name.
LECTURE XXXIII.
MELANOU), HiBMATOID, OSTEOID, VILLOUS, AND COLLOID CANCERS.
Of the three chief forms of cancer which I have now described, we may
observe, I think, that though two of them may be mixed in one mass, or
may occur at different times in the same person, or in different members
of the same family, and though there arc forms intermediate and transi-
tional between them, yet a mass of one of them does not, by any trans-
formation, assume the characters of another. A scirrhous cancer, I think,
never itself becomes medullary or epithelial ; neither does the converse
happen; nor do we see any indication that interference with the develop-
ment of a cancer of either of these forms would lead it into the assump-
tion of the characters of another. Combination, coincidence, succession,
or interchange of these three forms may be found ; but, I believe, no
transformation of a growth completed or in progress.
If this be true, it indicates that the degree of difference between each
two of these three forms is greater than that which exists between them
and the cancers to which I shall devote this lecture. For there seems
sufficient reason to believe that, by certain generally recognised processes
of degeneration or disease, a medullary or« epithelial cancer may become
melanoid or hsematoid ; that a scirrhous or firm medullary cancer may
become osteoid ; that the colloid character may be, in some measure,
assumed by either of the three chief forms ; and that either of them may
observe the villous or dendritic mode of growth. It need not always be
supposed that, in the transformations here implied, the cancer-structures
already perfected change their characters. It is probable, indeed, that
sucb changes do occur in some of the instances we have to consider ; but,
in others, we may rather believe that the peculiarities of structure are
due to something which induces degeneration or disease in the cancer-
elements in their most rudimental state.
The belief that the five forms of cancer, whose names head this lecture,
are modifications or varieties of one or more of the three already described,
may justify my describing them more briefly, and, in many parts, by
terms of comparison with the chief forms. Or, if this belief be not a
good reason for such a course, it must be sufficient, that the examples
of all these five forms are so rare, that complete and independent histories
of them cannot, at present, be written.
606 MELAKOID CAKCEB — STBUCTURB.
It is, I think, probable that other groups of cancers besides these might
be conveniently described as varieties of the principal kinds ;♦ but, at
present, it seems better to defer the introduction of new names till we
have attained more accurate knowledge.
MELANOID CANCER.
The Melanotic or Melanoid Cancers are, with very rare exceptions,
medullary cancers modified by the formation of black pigment in thdr
elemental structures. On this long-disputed point there can, I think, be
no reasonable doubt. I have referred to a case of melanotic epithelial
cancer (page 582) : but with this exception, I have not seen or read of
any example of melanosis or melanotic tumor in the human subject, whidi
might not be regarded as a medullary cancer with black pigment, hi
the horse and dog, I believe, black tumors occur which have no canceroos
character ; but none such are recorded in human pathology. The con-
ditions, which some have classed under the name ^' spurious melanosis,"
are blackenings of various structures, whose only common character is
that they are not tumors.
Melanotic cancers may have the general characters of any of the vari^
ties of the medullary cancer ; but the primary growths are rarely either
very firm or very soft. They may appear as infiltrations ; but are more
often, I think, separable masses. Their characteristic pigment marb
them with various shades of iron-gray or brown, deepening into deepest
blackness. The pigment is variously arranged in them. Sometimes, we
see, on the cut surface, a generally difiiised brownish tint, derived from
thickly sprinkled minute dots: sometimes, a whole mass is uniformly
black : sometimes, one or more deep black spots appear in the midst of a
pure white brain-like mass : sometimes (as in the specimen here figured),
in half a tumor there are various shades of brown and black, in the other
half the same texture uncolored : sometimes a whole mass is, as it were,
delicately painted or mapped as with Chinese ink. There are thus to be
found, in melanoid cancers, all plans and all degrees of blackening ; and
these diversities may be seen even in diffierent parts of the same tumor, or
in different tumors in the same person, f Nay, even in cancers that look
colorless to the naked eye, I have found, with the microscope, single cells
or nuclei having the true melanotic characters. And both the general
and the microscopic aspect of the disease may be yet farther diversified
by the coincidence of degenerations or hemorrhages, producing, in the
* This may be the case with what Mailer named Ccircinoma fasciculatum seu byalioom.
But, judging from his description and Schuh's, I cannot tell whether it is a disease which I
have not yet seen, or whether (as I am more inclined to believe) the name has not been
applied to some specimens of the soft, flickering, mammary or parotid glandular tumors, or
to die mammary proliferous cysts that are prone to recur (see pp. 3G4, 470).
t All these varieties are illustrated in the Museums of the Cullege and St Bartholomew's,
by specimens loferred to in the Indices of the Catalogues, vol. i. p. 133, and vol. i. p. sir.
HELAHOIS OAKOBR.
607
mblackened parts of the tumors, Tarious shades of yellow, or of blood-
Bolor.
In the dark turbid creamy or pasty fluid that may be pressed from
utelanotic cancers, the greater part of the
mcroscopic atmctiires are such as might ni.io«.*
belong to an micolored medullary cancer,
[t ifl often remarkable by how small a pro-
pratioD of pigment the deepest black color
maiy be giren to the mass : a hundredth part
of the comtitnent structures may suffice.
in^e pigment is generally in granules or
oaolecales : but it is sometimes iu nuclei or
in oorpnsclefl like them.
The majority of the pigment-grannies are
minate partides, not much unlike those of
the pigment-cells of the choroid membrane.
When out of focus, they appear black or
deep hromi ; but, when in focus, they have
peUncid centres, with broad black borders.
They appear spherical; and usually the
majority of them are free, >'. «., not enclosed i
iDolecnlar movement in the fluid that suspends them.
The greater part of the color depends on these free granules (fig. 107) ;
bat others like them are enclosed in the canccr-cells, or, more rarely, in
nnclei. Sometimes those in the cells are clustered round the nucleus ;
sometimes they are irregularly scattered ; in either case they appear as
if gradually increasing till they fill the cell, and change it into a granule-
mass, which, but for its color, we might exactly compare with the granule-
masses of fatty degeneration. While the pigment grauules are thus col-
lecting, the nucleus remains clear ; but at last, when the cell appears
like a granule-mass, it is lost sight of. After this, moreover, the d
1 Cells, and vibrate with
formed of pigment-granules may break up, and add their granules to
those which we may suppose to have been free from their first formation.
* FifT. 106. Seetkin of a TBriously ihiuled nelaiKad cancer Ibrmed beoealh a mole or pig-
meiiHcy ntrvu>. Muwum of St. Bariliolomew'g. Natural sixo.
t Fig. 107. Elemental (tiQclnrc* aT melanoid caocei, rereneit to in the text Magnified
608 MELANOID CAKOEB — PATHOLOGY.
The completely melanotic cells and their corpuscles, seen singly in the
microscope, look not black, but rusty brown or pale umber-broim : like
blood-cells, it is only when amassed that they give the fiill tint of color.
With the melanotic granules, there is sometimes a much smaller num-
ber of particles of the same color, and the same apparently simple
structure, but of larger size : from 50*00 to j^Sfjf of an inch in diameter.
These may be both free and in cells ; in the latter case, lying mingled
with melanotic granules in the contents of the cell. More rarely, cor-
puscles like the nuclei of cancer-cells, preserving their shape, size, and
apparent texture, present the characteristic brown tint. Such corpusclei
may be free ; but they may also occupy the place of nuclei in cells,
whose other contents are either uncolored or mixed with pigment-
granules : and more rarely, a single corpuscle of the same kind may be
seen in a cell containing an ordinary colorless nucleus.
In all the main facts of their pathological history, the melanotic
cancers are in close conformity with the' medullary ; and this may be
reckoned among the evidences that there is much less difference between
these two forms than there is between the medullary cancers and either
the scirrhous or the epithelial.
In the tables of 365 cases of cancer from which those in the fore-
going lectures were derived, there are 25 cases of melanoid cancer.
Seventeen of the patients were females, 8 were males. In 14 case?,
the primary seat of the disease was in the skin or subcutaneous tissue ; in
9, in the eye or orbit ; in 1, in the testicle ; in 1, in the vagina.* h
this limitation to a few primary seats, and in its proneness to affect cer-
tain abnormal parts of the skin, are the chief peculiarities of this variety
of cancer ; but on the other points which may be settled by counting, I
might have added the 25 cases to those of ordinary medullary cancer,
without disturbing the results stated in Lecture XXXI.
Thus, the ages of the patients at the access of the cancer were as
follows : —
Under 10 years - - 2
Between 10 and 20 " - - 1
" 20 and 30 « - - 7
" 30 and 40 " - - 4
" 40 and 50 " - - 5
" 60 and GO " - - 4
Above 60 " . - 2
The only notable difference in this table, when compared with that at
page 551, is in the inferior proportion of cases before 20 years of age ;
a difference mainly determined by the large number of cases of uncolored
medullary cancer of the eye in children.
Among 10 patients with melanoid cancer, one had had a relative who
* I once saw primary melanotic cancer of the liver j but I have no complete record of
the case.
KATUBB OF THB PiaMENT. 609
died with cancer of the breast ; another had many relatives with pigmen-
tary nsevi like that in which her own cancer originated. ^
In 20 of the cases, the previous history of the affected part is recorded.
In 8 of those in which the eye was affected it had been morbidly changed
by previous inflammatory disease ; in 2 it had appeared healthy. Among
the 14 cases affecting the skin or subcutaneous tissue, one patient as-
fligned no local cause ; 2 referred to injury, and were uncertain of the
previous condition of the skin ; in 10 the disease commenced beneath a
congenital pigmentary nsBvus, or dark mole; and in 1, in what the
patient called a wart of several years' standing. I shall presently
revert to these facts.
In regard to their rate and method of growth, their ulceration, and
their multiplying in parts near and distant from their primary seat, I
believe the general history of the melanotic cancers is parallel with that
of the medullary, given in a former lecture (p. 553, e. s.) But they
present even a greater tendency to multiply in the subcutaneous tissue,
growing here in vast numbers of small soft tubercles.
In like manner, the duration of life in melanotic nearly corresponds
with that in medullary cancers. In 18 cases, in all of which the pri-
mary disease was removed (but in two only partially), the durations of
life from the first notice of the cancer were as follows (and the table may
be compared with that in p. 561) : —
Between 6 and 12 months io 3 cases.
« 12 and 18 « 4 "
" 24 and 36 " 5 «
" 36 and 48 " 1 «
Above 48 « 5 «
Among 18 cases, whose history is known for some time after the
removal of the primary disease, one has survived for three years, another
for ten months, without recurrence of the disease. In the rest the dis-
ease recurred at the following periods (compare p. 562) : —
Between 1 and 3 months in 7 cases
" 3 and 6 « in 4 •*
« 6 and 12 « in 2 **
« 12 and 24 " in 2 "
« 24 and 36 « ml"
Seeing this close correspondence in their general pathology, the rules
respecting operations for melanoid cancers must be the same as for the
medullary. (See p. 563.)
■
I have reserved for separate consideration some of the peculiarities of
melanoid cancers* Three things in them especially deserve reflection,
namely — (1) their color ; (2) their proneness to take their first seat jp or
near cutaneous moles ; (3) their profuse multiplication.
1. The color of the melanoid cancers is due to a pigment-formation,
corresponding with that which we find, in the normal state, in the pig-
89
610 MELAKOID CAKGEB.
ment-cells on the choroid membrane, and in the rete mucosnm of colored
skins. Their usual primary occurrence near these seats of natural pig-
ments may, therefore, be regarded as an illustration of the tendency of
cancers to conformity, at least sometimes and in some respects, with the
characters of the adjacent natural textures.
But another meaning of the pigment in melanotic cancers is suggested
by its likeness to that which accumulates in the lungs and broncbial
glands in advancing years, and in the darkening cuticle of many old per-
sons. The coloring particles are probably different in these cases ; thej
produce different shades or tinges of blackness ; but their plans of forma-
tion and arrangement are in all similar. And the analogy of their
formation in the aged, and in some other instances (page 75), m&j
warrant us in regarding melanosis as a pigmental degeneration of medol-
lary cancer. The chief characters of its minute structures agree with
this, especially the gathering of pigment-molecules about the nucleus,
their gradually filling the cell-cavity, till, both the nucleus and the cell-
wall disappearing, the nucleated cell is transformed into a dark-colored
granule-mass. In all these characters there is an exact parallel between
the transformations of the cells in melanoid cancers and the usual changes
of the fatty degeneration. (Compare p. 498 and p. 579.)
2. The proneness of melanoid cancers to grow first in or beneath pig-
mentary moles is very evident : and I am not aware that such moles are
peculiarly apt to determine the locality of any other tumors ; for, except
a case (p. 568) in which an epithelial cancer grew from one, I have met
with no instance of other than melanoid cancers connected with them.
The fact is, I suppose, quite inexplicable ; but it may be usefully sug-
gestive. It seems a striking illustration of the weakness in resisting
disease which belongs to parts congenitally abnormal. It seems, also, to
be an evidence that a part may very long remain apt for the growth of
cancer, and not become the seat of such a growth, till the cancerous
diathesis, the constitutional element of the disease, is established. And
this event may be very long delayed : as in a woman, 80 years old, whom
I saw with a large melanotic tumor, which had lately grown rapidly
under a mole that had been unchanging through her long previous life.
But again, this peculiar affinity (if it may be so called) of moles for
melanoid cancers, may make us suspect that there may be other, though
invisible, defects of first formation in our organs, which may render them,
or even small portions of them, peculiarly apt for the seats of malignant
and other specific diseases. It is often only the color that makes us
aware of the peculiarity of that piece of a man's skin in which cancer,
if it ever occur in him, will be most likely to grow : and yet color is so
unessential a condition of texture, that we may well believe that all the
more real conditions of such liability to cancer may be present without
peculiarity of color, though, being without it, the part in which they
exist may not be discernible.
OONNBXION WITH MOLES. 611
I have spoken of the pigmentary moles as becoming the seats of mela-
* notic cancers. It might seem as if the mole were, in some sort, the first
stage of the cancer ; but it is not so : the structures and the life of the
mole are those of natural skin and epidermis, abnormal in quantity and
color, but in no more essential properties : there are no structures in
moles like those of cancer, till, at a certain and usually notable time,
cancer begins to be formed in them. And here let it be observed, how
dose is the correspondence in these respects between the pigmentary
moles, and the warts that are apt to become the seats of epithelial cancers
(p. 595). The patient is usually aware of a time at which a mole, observed
as an unchanging mark from birth or infancy, began to grow. In some
instances the growth is superficial, and the dark spot acquires a larger
area and appears slightly raised by some growth beneath it : in other
cases, the mole rises and becomes very prominent or nearly pendulous.
I believe that when the mole becomes thus prominent, the chief seat
of the cancerous formation is in the superficial layer of the cutis and
in the place of the rete mucosum; and that when it only extends
itself, the cancerous growth is chiefly in the skin and subcutaneous
tissue. In the former case, the cancer-structures are usually infil-
trated among the natural structures of the affected part ; in the latter,
they generally form a distinct tumor, which may be dissected from,
though it is closely connected with, the surrounding tissues and the
thinned layer of cutis and dark cuticle that covers it. (Fig. 106, p. 606.)
The general characters of the growths thus forming correspond, I
believe, in every respect with the medullary cancers of the skin and sub-
cutaneous tissue (p. 547) : color alone distinguishes them ; they are equally
prone to multiplicity. Often, in removing a deep-set melanotic mass,
smaller masses are found imbedded in the adjacent fat or other tissue ;
and sometimes the formation of one or more subcutaneous growths
almost exactly coincides with the outgrowth of the mole and its occupa-
tion by the cancer-structures.
8. The multiplicity of secondary melanoid formations is often very
striking. I have, indeed, seen one case in which, to the last, only the
lymphatic glands connected with the primary growth were diseased ; and
another in which only the liver and some lymphatics were affected ; but
the more frequent issue of the cases almost literally justifies the expres-
sion that the disease is everywhere. Are we to conclude from this that
the multiplication of melanoid cancers is more abundant than that of the
medullary cancers, which in other respects they so closely resemble? I
think not. We can easily see all the secondary melanoid formations, even
the smallest and least aggregated ; and it is often the color alone that draws
attention to many which, but for it, we should not have noticed. I sus-
pect that equally numerous formations exist in many cases of medullary
cancers, but are unseen, being uncolored.
612 FUKaUS HJBMATOBBS.
£LSMATOID CANCER.
This name may perhaps be retained to express a form of cancer which
Mr. Hey had chiefly in view when he proposed the name of Fungiu
Haematodes.* It is most probable that all the cases to which he gave this
name were soft medullary cancers; and his attention was especially
directed to the fact, that when the morbid growth protrudes through the
skin, the protruding portion may have such a shape as, in the conTen-
tional language of surgery, is called fungous, and often bleeds largely,
and is so vascular, or so infiltrated with blood, that it looks like a clot
The identity of the fungus haematodes of Hey with the meduUuj
cancers was fully recognised by Mr. Wardrop and others ; but unfortth
nately, certain foreign writers, regarding the hemorrhage as the distmc-
tive character of the disease, included under the same term nearly all
severely bleeding tumors of whatever kind.f It was an unhappy misiwc
of Hey 's name, by which he meant to express, not a bleeding growth, but
one like a clot of blood : and it led to a confusion which is still pre-
valent.
Leaving the term fungus hsematodes, we may employ that of hsmatoid
cancer, for such as are like clots of blood through the quantity of blood
that they contain. The likeness is, indeed, I believe, only an accidental
one, due to hemorrhage into the substance of the cancer, from rupture of
some of its thin-walled bloodvessels. It seldom exists in the wbole
mass of a cancer; but, usually, while some parts have the ordinary
aspect of medullary or some other form of cancer, other parts are blood-
like. The best illustration of the disease that I have seen is in a
large tumor,J of which one-half might be taken as a good type of the
brain-like medullary cancer, and the other half as an equally good type
of the haematoid. This half had been deeply punctured during life;
it had bled very freely, and the simultaneous bleeding into its own sub-
stance had, doubtless, changed it from brain-like to blood-like.
Probably any cancer may thus be made hsematoid ; but the change is
peculiarly apt to happen in those which are of the softest texture and
most rapid growth, and which are situated where they are least supported
by adjacent parts.
• Observations in Surgery, p. 239.
t Among the cases thus confused are some strange ones of profuse bleedings from sop*
posed growths, of which little or nothing could be found after death. Such a esae is related
by Mr. Abemethy (On Tumors, p. 127~note) ; and a specimen from Mr. Liston^s Museum is in
the Museum of the College, 302 a. It is perhaps impossible at present to say what tbaso
diseases were ; but I suspect they were medullary cancers with bloodvessels excessively
developed, like those of an erectile tumor.
X Mus. of St Bartholomew's, Ser. zzzv. No. 28.
08TB0ID OANOBB. 618
OSTEOID CANCER.
Miiller assigned the name of osteoid tnmor, or ossifying fungous growth,*
to a form of disease of which, with admirable acumen, he collected seye-
ral cases, illustrating these as its distinctive characters ; — that the pri-
mary tumor consists chiefly of bone, but has, on its surface and in the
interstices of its osseous parts, an unossified fibrous constituent as firm as
fibroDS cartOsge; and that, after a time, rimilar growths ensue in parts
distant from the seat of the first formed, and not on bones alone, but
in the cdlular tissue, serous membranes, lungs, lymphatics, &c. Mr.
Stanleyt has described the same disease under the name of Malignant
Osseous Tumor ; and single examples of it may be found under the names
of periosteal exostosis, fibrous osteo-sarcoma, foliated exostosis, ftc*
Mailer was disposed to call it osteoid cancer ; and certainly this name
is best suited to it, its intimate affinity with the other forms of cancer
being evident in these things — (1) its correspondence, in nearly every
particular of structure and of history, with the characters of cancerous
disease, as exemplified in the scirrhous and medullary forms; (2) its
not unfrequent coexistence with medullary cancer of the ordinary kind,
miher in a single mass of tumor, or in different tumors in the same per-
son ; (3) the uninterrupted gradations between it and the scirrhous and
medullary cancers ; (4) its mutations with the same, in hereditary trans-
mission or in secondary productions. I cannot doubt the propriety of
calling a disease cancer, in which these facts can be demonstrated ; and
I believe that the most probable view of the nature of osteoid cancers
would be expressed by calling them ossified fibrous or medullary cancers,
and by regarding them as illustrating a calcareous or osseous degenera-
tion. (See pp. 510-11, and compare p. 77.)
The primary seat of osteoid cancer is usually some bone ; but it is
not limited to bones. In a case by Pott,| quoted by Miiller, the primary
tumor lay ^Hoose between the sartorius and vastus intemus muscles."
In the Museum of St. Thomas's Hospital there is a tumor like an osteoid
cancer, which was removed from near a humerus, and. another from a
popliteal space. In all these cases, the removal of the tumor was fol-
lowed by the growth of medullary cancers with little or no bone in them.
Among the bones, the lower part of the femur is, with remarkable
predominance, the most frequent seat of osteoid cancer. Among 25
cases, of which I have seen histories or specimens, 13 had this part for
their seat : the skull, tibia, humerus, ilium, and fibula, were each affected
in two cases, and the ulna and metacarpus each in one case.
* Ueber ossificirende Schw&mme oder Osteoid-GeschwQlste : (Mailer's Archiv, 1843,
p. 396.) t On Diseaies of the Bones, p. 163.
^ Works, by Earle, iii. 3 13. I think that No. 2429 a in the College Museum may be regarded
as an osteoid cancer of the testicle, though the boue-like substance has not the characters
of perfect bone.
614
OBTBOID OAVOBK.
la most cases, the osteoid growth occnra coincidently within and on the
exterior of the bone, followingherein the usual rule of medullar; cancers;
but it may exist on the csterior alone : and I have twice seen its fibrou
baaiB in the cancellouB tissue of a bone, of which the exterior wu Btl^
rounded with soft medullary cancer.
In the best examples of osteoid cancer, i. e. m those in which its pecu-
liar characters are moat marked, it presents, if seated on a long bone,
such as the femur, an elongated oval form ; if on a flat bone, a bicoDTei
form. Its elongated shape on the femur, the swelling gradually riamg
as wo trace down the shaft, and then rather less gradually subsiding at
the borders of the condyles, is almost enough for a diagnosis of the ot-
tooid cancer from other hard tumors. It is like the enlargement pro-
duced by simple thickening of the bone or periosteum : a likeness wtiidi
is increased by the smoothness of surface, the nearly incompresuble hud-
ness, and the considerable pain, which, in general, all these Bwellingi
alike present.
When we dissect down to an osteoid cancer (taking one on the femnr
for a type) we usually find the adjacent
^■y*-' tissues healthy, exceptjn being stretched
round the swelling. Small massee of
fiim cancer may, however, be imbedded
in them, distinct from, but clustered
around, the chief mass. The periosteum
is usually continued over the cancer,
but scarcely separable from it. The
surface is smooth, or very lowly and
broadly tuberous. A section generally
shows that the exterior of the growth
is composed of a very firm, but not
osseous, substance ; while its interior
part, i. e. that which lies nearest to the
shaft, and that which is in the place of
the cancellous tissue, are partially or
wholly osseous. The two substances
are closely interblended where they
meet ; and their relative proportions
difi"er much in different specimens, ac-
cording to the progress already made by
ossification.
The unossified part of the tumor
is usually exceedingly dense, firm, and
tough, and may be incompreasibly hard ; its cut surface uprises like that
of an intervertebral fibrous cartilage, or that of one of the toughest
eiaucTURB. 615
fibrous tmnorB of the uterus. It is pale, grayish, or with a Blight yellow
or pink tint, marked vith irregular short bars of a clearer white ; rarely
intersected as if lobed, but sometimes appearing banded with fibres set
▼erticallrf on the bone.
The bony part of the tumor, when cleared by maceration, has charac-
ters altogether peculiar (fig. 108). In the central parts it is (in the best-
marked specimens) extremely compact, scarcely showing even any pores,
white, and dry. To cut, it is nearly as hard as iyory, yet, like hard chalk,
it may be rubbed or scraped into fine dry powder. At its periphery it
is arranged in a knobbed and tuberous form, the knobs being often
formed of close, thin, gray or white lamellte, whose presenting edges give
them a fibrous look, exactly like that of pumice-stone. In this part, also,
the bone is very brittle, flaky, and pulverulent.
In some specimens the whole of the bone has this delicate lamellar
aod brittle texture ; but more generally, as I have said, the central part
H very hard, and this, occupying the walls and cancellous tissue of the
■haft, equally with the surrounding part of the tumor, makes of the whole
nich a compact white chalky mass as the sketch represents (fig. 108).
In the osteoid cancers of the lymphatic glands (fig. 109) and other
soft parts, the bone is finely porous, spongy, or reticulated ; or it may be
finely lamellar, and look fibrous on its surface. It is always soft and
britUe, and, often, it has in these parts no regular plan, but is placed in
Hmsll close-sot grains or spicules, which fall apart in maceration. In
whatever plan or part the bono is found,
it has no medulla; its interstices are
filled with cancer-substance.
When the salts of lime are removed
firom the bone with acid, an organic
basis-substance remains, which presents
the same general aspect as the unossified
part of the cancer, while retaining the
Imnellar and fibrous arrangement of the
bone.t This basis yields gelatine ; and
the saline constituents are similar to those of ordinary bone, but with a
^proportionate preponderance of phosphate of lime (Muller, I. c. p.
412).
With the microscope, the unossified part of an osteoid cancer appears
fasciculated or banded, and is always very difficult to dissect. In some
specimens, or in some parts, it has only a fibrous appearance, due to
markings and wrinkles of a nearly homogeneous substance, in which
abundant nuclei appear when acetic acid is added. In others, it is dis-
tinctly fibrous, but not in all parts with the same plan. The fibres are
sometimes moderately broad, about jt^o of an inch wide, have uneven,
thorny edges, and, arranged in bundles, look like faggots (fig. 110, a).
■ Fig. 109. Section of fin inguinal lympUnlic gland, with osteoid cancer, after maceialioQ.
Nu Mxe. Mus.or St. BartlioloinswX Sei. i. No. 109. t Mu*. ColL Surg. No. SOS.
616 OSTEOID CANCBB.
In other parts they are finer, like sharp-edged, crisp, and stiff filaments.
Such as these may present a nearly regular reticular arrangement, with
Pig. no*
well-formed meshes (b) ; or they may be nearly parallel, and construct a
more distinctly fibrous texture (c) ; or they may be closely matted, and
except in their exceeding toughness, may be like the short, crooked fila-
ments of a fibrine clot (n). I never saw them presenting the undulating
glistening aspect of the filaments of an ordinary fibrous tumor, or of
natural fibrous tissue.
Fibrous tissue, in one or other of the forms just mentioned, makes np
the main mass of the unossified part of the cancer. But other elemental
forms usually exist with it. Sometimes cancer-cells are mingled with it,
as if imbedded in the interstices of the fibres. They are of ordinary
form, not differing from those of common scirrhous cancers in anything,
unless it be in that they are smaller and less plump. Sometimes granule-
masses and minute oil-molecules are scattered among the fibres. Both
these and the cancer-cells appear foreign to the fibrous tissue, as mingled
with it, not part of it ; but, if acetic acid be freely added, the fibrous
tissue becomes clearer, and we find (what may before have been very ob-
scurely seen) abundant nuclei imbedded in it. They are generally oval,
smooth, well-defined, from 5^00 to ^g'^u of an inch in length ; but, I think,
as the fibrous tissue becomes more perfect, they shrivel and become
crooked, or like little stellate cracks in the basis-substance ; or else that,
as it ossifies, they are imbedded in the accumulating lime-salts, and be-
come the lacunae of the bone.f
Structures such as these exist in the osteoid cancers of all parts ; and
when a series of those occurring in the lymphatics and other organs can
be compared with the primary disease on the bone (for example), I believe
no other difference will be found, than that the secondary cancers are
less definitely fibrous, and have a larger proportion of cancer-cells or
granule-masses, than the primary disease. These, however, are no
greater differences than may be found in comparing the less with the
more firm parts of a single primary mass of the disease.
The microscopic characters of the ossified part of the cancer are those
* Fig. 110. Fibrous tissue of an osteoid cancer, in different forms, as described in the text
Magnified 400 times,
t Gerlach also describes this in his Essay, Dor Zottenkrebs und das Osteoid, p. 52.
PATHOLOGT. 617
of tnie bone, but rarely of well-formed bone. In some parish— especially
in the secondary cancers — ^tbat which appears to be bone is only an
amorphous granular deposit of lime-salts, like those in ordinary calcareous
degenerations. In other parts the lacunse of true bone are distinct,
but they are small, and their canalicules are few and short, and without
order. Haversian canals also exist with these, but they have not a large
Beries of concentric lamellse like those in normal bone. In other instances,
hut these are rare, the lacunse are more nearly perfect ; their canalicules
communicate with one another, and with the cavities of the Haversian
canals. The bone with distinct lacunae and canalicules is not found ex-
dusiyely in the primary cancer, or near the natural bone on which it is
seated : here, indeed, the complete bone is most frequent ; but it may be
found, also, in the secondary growths in the glands and elsewhere. These
differences between the bone of the primary and that of the secondary
osteoid cancers, like the similar differences of their unossified parts, are
only differences of degree, such as may be found in separate parts of the
same mass ; they are, probably, to be ascribed only to more recent or
more rapid growth.
The foregoing description of the osteoid cancers may suffice to show
that their nearest affinities, judging by the structure of their unossified
part, are to the fibrous cancers, of which I spoke at p. 510, and to the
firmest of the medullary cancers (p. 536). When abundant cancer-cells
are present they most nearly resemble the latter form ; when they are
almost wholly fibrous, the former. Their peculiarity, as cancers, is in
their ossification. In this they may seem to approximate to the non-can-
cerous tumors; but, really, they remain, even when ossified, very distinct
from any of them. I have enumerated (p. 466) the characters by which
they are distinguished from both the hard and the cancellous osseous
tumors ; and the difference is as complete, and, I believe, as constant, as
that of their fibrous basis is from the structure of any non-cancerous
fibrous tumor.
If we consider only their osseous part, the osteoid cancers most nearly
resemble those soft medullary cancers which have the most abundant
internal skeletons. There is, indeed, no absolute line of distinction to be
drawn between the two. It may be very evident, in the typical specimens
of each, that the skeleton of the soft medullary cancer is formed by ossifi-
cation of the intersecting and overgrown infiltrated periosteum (p. 535) ;
and that the bone of the osteoid cancer is formed by ossification of the
proper cancerous substance ; but, between these extremes or types, there
are numerous instances in which the two conditions are mingled, or
through which the one condition merges into the other. And this is no
more than we might expect, seeing the frequency Ynih which the osteoid
and the medullary disease appear together, or in succession.
The materials for a general pathology of osteoid cancers are very
618 08TS0ID OAHOER.
scanty ; yet one may be written ; for if we collect only well-marked tv *r
amples of the disease, their histories will be found consistent witk om |
another, and distinct from those of the other groups of cancers.
Among 20 cases, 15 occurred in men, and 5 in women : a pnpoa-
derance on the male side approximating that observed in epithelial aa-
cers, and (if we may trust to a result from so few cases) contraftia^
in a striking manner, with the distribution of meduUarj and iciiTlKMi
cancers.
Among 19 of these patients, 5 were between 10 and 20 years oU; 9
between 20 and 30 ; 4 between 30 and 40 ; 1 between 40 and 50: — pi^
portions which again do not correspond with those in any other form d
cancer.
Among 18 of the patients, 5 distinctly referred to injury as the origia
of the cancer, and 2 to previous disease in the part : the others muigbtk
no cause.
The growth of osteoid cancers is generally rapid, and acconpanifl
with severe pain in and about their seat ; their multiplication in the iT»
phatics and in distant parts takes place with proportionate rapidity ; sal
intense cachexia occurs early in their course. There are exceptioai »
these things ; but in all these respects the majority of the osteoid cucca
appear as malignant as the medullary, and are as quickly fatal.
Among 14 cases, of which the ends are recorded, 3 died in conseqaatt
of amputations. Of the other 11, 4 underwent no operation, and all diei
in or within six months from the first notice of the dij«ease. Of the re-
maining 7, in all of whom the disease was once or more removed, and ii
all of whom it recurred before death, 2 died in the first year of it# tTn-
tence, 1 in the second, 1 in the third ; but one lived for 7 J years, anotbtf
for 24, and another for 25 years.
In all the instances of speedy death, secondary osteoid cancers cx^iei,
and the result was probably to be assigned to these and to the coinchlci:
* cancerous cachexia ; for the primary growths have little tendencj lo
ulcerate or protrude, and they seem to contribute directly to death tj
their pain alone. In the instances of life extended beyond twenty vtars^
the disease appeared to recur only near its primary seat.
The most frequent seats of the secondary, or recurrent, osteoid canoen
are the l^Tnphatic glands, in the line from the primary seat to the ih->-
racic duct, the lungs, and the serous membranes : but it is not limiteii to
these ; it may be found even in the bloodvessels, as in a case which I
shall relate, and has been traced in the thoracic duct."^ Its conJitioo
in these secondary seats need not be described : in structure it re^ml'l«i
in them the primary disease, with only such difiercnces as are alrtadj
mentioned ; in plan it is like the growths or infiltrations of secouiiArj
medullary cancers in the same parts. But it is to be observed that, t<»iw-
times, the secondary cancer is medullary, without osseous matter. I
* Cbeston, in Pbitot. Tnmi. 17S0, voL Ixx.
. PATHOLOQY. 619
hftye mentioned three instances of this (p. 613), and Professor Langen-
beck told me that he once removed an upper jaw with a bony growth,
and the patient died soon after with well-marked medullary cancer in the
longs. The reverse may occur : for the same distinguished surgeon told
me that he once removed a humerus with a medullary cancer, and the
patient died with osseous tumors in the lungs.
The ordinary course of osteoid cancers may be known by the foregoing
account of them, and by the cases recorded by MUller and Mr. Stanley.'*'
But deviations from this course are sometimes observed, which it may be
well to illustrate by cases that displayed the disease in an unusually acute,
and an equally unusual inactive, form.
A girl, 15 years old, was admitted into St. Bartholomew's Hospital,
with general feebleness and pains in her limbs, which had existed for two
or three weeks. They had been ascribed to delayed menstruation, till
the pain, becoming more severe, seemed to be concentrated about the
lower part of the back and the left hip. A hard deep-seated timior was
now felt, connected with the ala of the left ilium. This gradually in-
creased, with constant and more wearing pain ; it extended towards the
pelvic and abdominal cavities ; the patient became rapidly weaker and
thinner ; the left leg swelled ; sloughing ensued over the right hip ; and
thus she died cachectic and exhausted, only 3^ months from her first
notice of the swelling.
A hard lobulated mass was found completely filling the cavity of the
pelvis, and extending across the lower part of the abdominal cavity. It
was firmly c^nected with the sacrum, both ischia, and the left ilium ; it
held, as in one mass, all the pelvic organs ; and the uterus was so im-
bedded in it, and so infiltrated with a similar material, that it could
scarcely be recognised.
The general surface of this growth was unequal and nodular. It was
composed of a pearly-white and exceedingly hard structure, in which
points of yellow bony substance were imbedded, and which had the cha-
racters of osteoid cancer perfectly marked. The ilium, where the tumor
was connected with it, had the same half fibrous and half bony structure
as the tumor itself.
The common iliac veins, their main divisions, and others leading into
them, passed through the tumor, and were all distended with hard sub-
stance like the mass around them. From the common iliac veins a conti-
naous growth of the same substance extended into the inferior cava, which,
for nearly five inches, was distended and completely obstructed by a cylin-
driform mass of similar fibrous and osseous substance, 1^ inches in dia-
meter. At its upper part this mass tapering came to an end near the liver.
The lower lobe of the right lung was hollowed-out into a large sac, con-
taining greenish pus and traversed by hard coral-like bands, which proved
* L. c. See also Garlach's two cases (I. c.) and that by Hunter, in the Catalogue of the
College Museum, yol. iL p. 176.
620 VILLOUS OAKOBB.
to be branches of the pulmonary artery plugged with firm white sub-
stance intermingled with softer cancerous matter, and resembling the
great mass of disease in the pelvis. The rest of the lung was healthy,
with the exception of some scattered grayish tubercles ; and so was the
left lung, except in that there were a few small abscesses fiear its surface,
with hard, bone-like masses in their centres, like those in the branches of
the right pulmonary artery. The skull, brain, pericardium, heart, and
all the abdominal organs, were healthy.*
I suppose that few cases of osteoid cancer can be found equal with tlus
in the acuteness of their progress. The opposite extreme is illustrated
by a case communicated to me by Mr. Thomas Sympson, and exactly
corresponding with one of which the specimens are in the Museum of the
College.f A swelling appeared in the upper arm of a woman 82 yean
old. After ten years growth, when it had increased to seven pounda
weight, it was removed by Mr. Hewson. It had the characters of osteoid
cancer. The patient completely recovered from the operation ; but,
about a year after it, a new tumor appeared about the humerus, and at
the end of four years had acquired a huge size, and a weight of 15J pounds.
For this, which proved to be a similar osteoid growth, the arm was ampu-
tated at the shoulder-joint. She recovered from this operation also; but
the disease returned in the scapula, and, in about 10 years after the
amputation, and 24 years from the beginning of the disease, she died.
VILLOUS CANCER.
Villous Cancers (Zottenkrebs of Rokitansky),| are varieties of
Medullary, and, perhaps, in some instances, of Epithelial Cancers ; but
they demand a separate description, not for their own sake alone, but
because they illustrate a remarkable mode of growth, which probably
prevails in a much wider range of morbid structures than it is yet clearly
traced in.
Among the best examples of the villous cancer are those which occur
on the mucous membrane of the tirinary bladder, and of which an excel-
lent specimen, in the Museum of the College, is represented in the oppo-
site sketch. Here the cancer appears of oval or spheroidal shape, at-
tached to the mucous membrane by a narrow base, and pendulous in the
cavity of the bladder. Its base and central part may be solid, either
moderately firm, or soft, like an ordinary medullary cancer, yielding
abundant creamy fluid ; but all its unattached and peripheral part is
very soft, tufted, shreddy, and flocculent, like the surface of a chorion.
It is covered with fine villous processes that float out in water, and are
usually bright or dark red, with the full bloodvessels which they con-
• The specimens from tliis case are in the Museum of St. Bartholomew's.
t No. 3244-5-5 a.
X Ueber den Zolleii\LTe\>«, va ^e ^\\z\vx\%i^)«tv:^Ex\& ^«i\a^%. fJudomie ; April, 1852.
DENDRITIC VEQKTATIOIT.
and from which, during life, profuse hemorrhages are apt to octur.
Vo or more such cancerous grontha may stand near together ; or
■e may be, according to
pdtitanfiky, a collection of de- "^' '"■'
nte, spongy, and branched
Sous excrescences, rbing
om a circumscribed base ;
■ a diffuse growth of uume-
us fiiugle tufts scattered over
wider extent. Commonly,
le surrounding mocous mem-
«ne appears reticulated with
fine-meshed trellis- work,
om the bars of which very
plicate excrescences, rise, in
he form of fine vesicles or
Ti-t
Growths, such as these are
I the mucous membrane of
e bladder (their most fre-
pent scat), may occur in many other parts. Rokitanaky describes
"lem in the stomach, the rectum, the gall-bladder, J the interior of
rarian cysts, on the peritoneum,§ and the dura mater. In all these
jeitiona the cancer projects into cavities, and finds, probably, the
lOst favorable conditions for its characteristic method of growth ; but
lOkitansky has ah!o observed similar growths in the brain, the liver,
ad the uterus ; in the last-named organ growing first in its very sab-
MsQce, and thence protruding into its cavity.
I have had no opportunity for many years past of minutely examining
ill-marked villous cancers. I will therefore describe their construction
an abstract of Rokitaosky's Essay.
The excrescence consists, in its stem, of a fibroid membranous struc-
re, on which the branches and villous docculi are borne, as larger and
laller pouch-like and flask-shaped budtlings, or sproutings of a struc-
teless hollow tissue.
The *' dendritic vegetation," of which these sproutings are an example,
IBS been already often referred to, especially in the account of the stroma
of the iirinnry Jjlnddi
• Vitloui cance
illioColleB*'Miueura:lhefi6Ui
Uie ProglBte Gland," v
3, 7, aad SS, ]n Ser. uviL ii:
.If the nnrural aine. Tho specimen is No. 2005
,'is coiiied Ctoni thai by Clifl in Sic E. Home's " Obser-
p. 40, pi. X. No. aOOQ in ibe College Muieum, and
the Museum or St. Baclliolomew's, are similat specimeiu.
I. "f So in the muooiis membnme of a cancerotis stomach in (he Museum ot Sx, Bartbolo-
S. Getlach righdy dwells on this state, and tho smnllet iatt» ibat surround the
Mun disesae, as constituting a prepsrHtory villous or papillary, but not yet cancerous, (lala.
parallsl wiili ihni or llie warly giowlhs tlinl may precede and become the saau
epitlidial cancer. X Museum uf St. Bartbolomew's, xii. 3.
i An exquisite ipecimen of thii i* io the Muieum of St. Bsnliohiniew't, xi
622
VILLOUS CANCBB.
of medullary cancers* (p. 542), which stroma is, indeed, only another
modification of the same plan of growth as the villous cancers exemplify
in a clearer form. Other examples are in the endogenous growths of
cysts ; in the Lipoma arborescens of MUller (i. e. the tufted and villoia
growths on synovial membranes; and in the intracystic growths of
thyroid and other gland-substance illustrated in the twenty-third lecture,
(p. 357, e. s.).
The " dendritic vegetation" appears originally as a hollow club-shaped
or flask-shaped body, consisting of an hyaline structureless membrane.
It is either clear and transparent, or opaque, i. e, filled with granules,
nuclei, and nucleated cells (fig. 97, p. 543) : externally, it is either bare
or covered with epithelium. The vegetation does not usually developc
itself into villous growths directly on the mucous or other surface on
which it rests, but on the bars of some previously formed meshed-work,
such as is described at pp. 548 and 621. The further development of the
vegetation is commonly in one of two chief plans. Either the membra-
nous flask grows uniformly into a sac, which contains a serous fluid, or
is filled with a delicately fibrous meshed-work ; or else it grows and
Kg. 112,t
B
sprouts in various degrees and methods. Of this sprouting growth,
which alone is illustrated in villous cancer, there are three types. They
are represented in the adjoining copy of Rokitansky's sketches.
In the first (fig. 112, a), the flask grows out in low, nearly hemispherical
sprouts. These may contain serous fluid, as in the cystic disease of the
choroid plexuses ; or they may be filled with gland-structures, as in the
thyroid and mammary intracystic growths ; or they may contain and be
covered with cancerous structures, as in the instance of the small ex-
crescences within a cyst in a cancerous kidney, from which fig. 112, a,
was drawn.
• The following pages contain the fuller truth of what is said in a note at p. 357, which
was printed before I received the two essays by Rokitansky tliat are cited here and at p.
542. The same views which these essays expound were stated by him in those published
in 1840, on Cysts and on Bronchocele, but so much less clearly, that I did not fully see their
bearing on the pathology of the endogenous growths in proliferous cysts. The reader must
not fail to observe how much of the truth concerning these cancerous growths was expressed
by Dr. Hodgkin.
t Fig. 112. Method* of f^rowth of the ** dendritic vegetation," from Rokitansky. Magnified
30 times : explained \t\ \\\e \ex\.
VILLOUS OANOBB. 628
In tba. second type (fig. 112, b), the flask grows lengthwise into a tube,
and shoots ont new ones, which grow to secondary tubes, and again
shoot out others, which grow to tertiary tubes, and so on. On these
outgrowths abundant broader sprouts and buds appear. Thus a multi-
formly ramified dendritic-structure is produced. Its sprouts may be
filled with fibro-cellular tissue, or fat (as in Lipoma arborescens), or
with cartilage and bone (as in the pendulous growths of these tissues
within joints) ; or they may contain and be covered with the elements of
tke cancer, as in the villous cancer of the urinary bladder, of which part
is sketched in fig. 112, b.
In the third type, illustrated by fig. 112, o, from another villous cancer
of the bladder, the flask grows with considerable dilatation into a stem,
which gives off branches that do not ramify further, but break up at
once into a great number of flask-shaped sprouts.
The usual arrangement of the bloodvessels of the dendritic vegeta-
tions is that (as in the synovial fringes and the villi of the chorion) a
vessel runs along the contour of the vegetation, forming frequent loops,
and supplying to the stem, as well as to each of the sprouts and branches,
an ascending and a descending vessel. There are, however, pouches in
the vegetation in which only a single vessel exists, and terminates with
a rounded end. The vessels are generally large, examples of the so-
called colossal capillaries, thin-walled with longitudinal, and sometimes
also transverse, oval nuclei in pellucid membrane.'*'
In structure, the vegetation in villous cancers is often hyaline ; that is,
it contains, besides a clear fluid, no tissue-elements ; but it often contains,
together with its bloodvessels, a quantity of elementary granules, nuclei,
and cells, and, especially at the ends of its sprouts, structureless simple
and laminated vesicles. On its exterior, the elements of a medullary or
melanotic cancer-juice adhere to it, consisting of nucleated cells of various
shapes, which form a soft, or a more consistent, deposit, and are often
present in such quantity that they make up the greater part of the
morbid mass, into which then the vegetations seem to grow.
In other cases, a fibrous texture developes itself in the interior of the
vegetation, and with it cancerous elements form, like those of the exo-
genous formation just mentioned. In this state the villous cancer, in
consequence of the accumulation of the fibrous and cancerous structures,
appears as a collection of excrescences which, in their stems as well as
in their branches and sprouts, and especially towards their free ends, are
swollen thick and big. They are here filled with a delicately fibrillated
meshed-work, turgid with medullary cancer-juice ; and, as their swollen ends
are often mutually compressed, the whole appears like foliage growing
on shorter or longer stems.
When the villous cancer is cut through to its base, one finds a tolera-
* Gerlaoh^s account of the bloodyessels nearly corresponds with this (Der Zottenkrebs
und da« Osteoid, Ta£ i. fig. 3).
624 INTERIOR STRUCTURE.
blj abundant porous fibrous texture, which, on nearer examination, pre-
sents a compressed meshed-work traversed by fissure-like apertures. Its
bars consist of a hyaline substance, beset with oblong nuclei and nudeoa-
fibres, and here and there dividing into filaments of connective-tiflsue.
The tissue {e. g. of the mucous membrane) around the base of the cancer is
traversed by a whitish fine-meshed trellis-work, the bars of which coosist
of nucleated cells, and often develope delicate prominences and vesicles,
the beginnings of the kind of vegetation from which the cancer sprang.
The fissured and perforated meshwork in the interior of the base of
the villous cancer corresponds with the stroma of ordinary medullary
cancers (p. 543). Both are constructed on the plan of the dendritic
vegetation. In the construction of the stroma, the sprouting growths
become a meshed-work by partial absorption : in the villi of the villous
cancer they lengthen into branching tubes. And these tubes have, on
the one hand, the import of a stroma, in that the cancerous elementary
structures cover them and fill up the spaces between them, as they do
those between the bars of the more ordinary stroma. But, on the other
hand, the tubes have a nearer and distinctive relation to the cancerous
elements, in that they produce those elements in their interior ; so that
there is an endogenous as well as an exogenous production of caneer*
structures.
In all the instances that have been fully examined| these structures
have been like those of medullary or melanotic cancer. But I belieTe
Rokitansky is right in the anticipation that certidn epithelial cancers
will be found to grow on the same plan as the villous. I have referred
(p. 569) to instances of warty epithelial cancers growing where they could
not have had origin in natural papillae ; Yirchow also describes arbo-
rescent epithelial cancers growing in cavities where no papillse could well
be ; and I have seen the same in cysts within what I believe to be an
epithelial cancer of the clitoris.'*' The shapes of the most exuberant
epithelial cancers so imitate those of the villous cancers, that it seems
highly probable that some of them are produced by the dendritic mode
of growth, rather than by the enlargement and deformity of papillae.
The correspondence of the stromal structures, and the exact similarity
of the cancer-elements, found in the medullary and melanoid cancers on
the one hand, and in the villous cancers on the other, are enough to war-
rant us in regarding these as varieties of the more general form. This
view is confirmed by numerous cases in which the central and basal parts
of the growth are like common medullary cancer, its surface being villous;
and by some in which villous cancers appear as secondary growths with
primary medullary cancers of the more common kind : thus, e. g. the
former occur on the peritoneum, with the latter in the ovaries. It may
be anticipated that the histories of the villous cancers will equally coin-
cide with those of the medullary and melanotic; but, as yet, the cases re-'
corded are too few for the deduction of any general rules.
OOLLOID OANOBB. 625
COLLOID CANCEB..
Many names have been given to this form of cancer — Colloid, Alveo-
lar, Grelatmiform, Cystic, and Gam-Cancer. I have adopted the first,
because it seems to be now most frequently used, and expresses very well
the most obvious peculiarity of the diseased structure, the greater part
of which is, usually, a clear flickering or viscid substance like soft gela-
tine.
The most frequent primary seats of colloid cancer are the stomach, the
intestinal canal, uterus, mammary gland, and peritoneum : as a secondary
disease, it affects most frequently the lymphatic glands and lungs, and
may occur in many other parts.
To the naked eye, a colloid cancer presents two chief constituents :
an opaque-white, tough, fibrous-looking tissue, which intersects, parti-
tions, and encloses its mass ; and a clear, soft, or nearly liquid material,
the proper '^ colloid" substance. According to the proportions in which
these are combined, the general aspect of the disease varies. When the
fibrous texture is predominant (as I have twice seen it in the central
parts of colloid cancers of the breast) it forms a very tough, white, fascia-
like mass, in which are small separate cysts or cavities filled with the colloid
substance. In the opposite extreme, large masses of the colloid sub-
stance appear only intersected by fibrous white cords or thin membranes,
arranged as in areolar tissue, or in a wide-meshed network. These
extremes often exist in different parts of the same mass, and with them are
various intermediate forms, in which, probably, the essential characters
of the disease may be best learned. In these, the cancerous substance
appears constructed of small thin-walled cysts, cells, or alveoli, arranged
without apparent order, and filled with the transparent colloid substance.
The cysts or alveoli are, typically, of round or oval form, but are changed
from this, as if by mutual pressure ; some may appear closed, but the
great majority communicate with those around them, through apertures
like imperfections in their walls. They vary from an inch in diameter
to a sise as small as the naked eye can discern. The largest cysts, and
the least abundant fibrous tissue, are usually at or near the surface of the
mass ; and in these large cysts, when the colloid substance is emptied
from tiiem, we can generally see intersecting bands, or incomplete parti-
tions, as if they were formed by the fusion of many cysts of smaller
rise. The walls of the cysts appear formed of delicate white fibrous
tissue, but cannot be separated from the surrounding substance, and are
oondnuous with the coarser bands or layers of fibrous tissue by which
the cancerous mass is intersected.
The colloid matter is, in different parts or in different instances, various
in consistence; resembling a thin mucilage, starch-paste, the vitreous
humor, size-gelatine, or a tenacious mucus. In its most normal state, it
40
626 OOLLOIB OAVOXB.
is glistening, translucent, and pale-yellowish ; but it may be ookilM, or
may have a light green, gray /pink, or sangoineoas tint ; and may bceoM
opaque, whitish or buff-colored, by (apparently) a fatty or eakufoa
degeneration ; or, in the extreme of tUs degeneration, may kiok lii
tuberculous matter. In water, or in spirit, it ooses from the alTeofi tii
floats in light cloudy flocculi ; and when the surface of the cancer is ex*
posed by ulceration or by rupture, it is discharged from the opened ahwi
and lies on them like a layer of mucus*
The colloid cancers hay^, usually, in the first instance, the shape rf
the part that they affect ; for they are always, I beliere, infiltratioiis <if
the affected part, whose tissues are gradually removed and sopeneded hj
their growth. But the growth of the colloid cancer enlarges and wm-
passes the part in which it is seated, and produces, in such an efgm ai
the breast or the lymphatic glands, a considerable rounded and tibcrw
firm swelling, or, in such an one as the stomach or the peritooeom, a fat-
tened expanded mass with more or less of nodular or tuberoos projcctioa
The extent of growth is sometimes enormous, especially in the perils
neum, in which, as in a case related by Dr. Ballard,* the greater pirt if
the parietal and much of the visceral portion may be infiltrated with tk
morbid structure, either in a nearly uniform layer, or in nodulated suit
ings formed of groups of cysts, and sometimes projecting far into tk
peritoneal cavity. The cavity itself may, in these cases, contain fift
colloid matter, discharged, I suppose, from the open superficial alvooii,
and the abdominal walls may be thus distended with a fluctnatinir Tibn^
ing swelling like that of ascites.t
It is not unfrequent to find one or more large and thick-walled cjw
near or attached to masses of colloid cancer, and imitating the charactcn
of such proliferous multilocular cysts as are found in the ovarica. TWr
are usually filled with colloid matter, and their likeness to the ofiriifi
cysts may confirm the belief that many of the latter are really coUoii
cancers of the ovaries.
Moreover, colloid cancer is sometimes found mingled in the same mm
with medullary cancer. This is, indeed, frequent in the digestive cuaL
Villous and melanotic cancers have been similarly combined with it; tal
more frequently, in different parts of the same person, the medoUary sai
the colloid are found in distinct masses.
Microscopic examination of fragments of colloid cancer brings iatc
view an arrangement of delicately fibrous and lamellar structures, imita^
ing, in miniature, the larger appearances visible to the naked eye. Fme
• Med.XJhir. Trans., xxxi. 119.
t In Dr. Ballard's case, six quarts of free colloid matter were mnored flom dw
cavitjr after death. I remember an exactljr similar case in which, I think, the
removed must have been greater, and in which it certainly appeared lo be deriTed (torn ^
dehiscence and constant discharge of the alveolL In the Museum of the Collefe, Xa 2^
is a mass of peritoneal colloid cancer, from eight to ten inches in its diameters, which «•
xemored from the lower surface of a liTer.
HIOBOKOOPIO STBCOTHES. 627
tough fibres, or fibred membraoefl, are arranged in curved bnndles and
bmells, which, by their divergenceB and interlacements, encircle or
enclose oval or spherical spaces,
eontuning the colloid substance. Pig.iia.»
The enclosed spaces are seldom
complete cavities; they oommuni-
cate freely vith one another ; and
both in their plan, and in the gene-
ral aspect of the tissue, remind one,
as Lebert says, of the structure of
a lung, Tith its communicating air-
cells. The fibres are very fine, but
appear stiff and tough, not undulat-
ing nor easily parting ; they are but
IHtle and slowly changed by acetic
add. Elongated nuclei are often seated on these fibres, and sometimes,
Lebert says, elastic fibres are mingled with them. The colloid substance
fills all their interspaces, not merely the cavities which they circnmscribe,
bat, as it were, mere crevices between the fibres, and spaces in the walls
of the larger cavities.
The colloid substance generally appears, however magnified, clear and
stTDctnreless ; it might be invisible but for the seeming filamentous tex-
ture produced, as it often is in spread ont masses, by its folds and creas-
ings. Sometimes, the colloid material is sprinkled with minute dots, like,
oQy or fatty molecules, f which to the naked eye may give it a pecuh'arly
milky or ochrey aspect; and sometimes it is beset with clusters of such
molecoles, resulting apparently from the degeneration of imbedded nuclei
or imperfect cells. With these, also, crystals of the triple phosphate,
cholestearine, and some peculiar fatty matter,]; may he mingled.
Lebert § has published an exact analysis of this colloid matter by
Wortz. The main results are, that it is quite unlike any variety of gela-
tine, being insoluble in water, and containing only 7 per cent, of nitro-
gen, a peculiarity which distinguishes it as well from allprotein compounds,
and from the materials of which (imperfectly and impurely as they have
been examined) the essential structures of other cancers are composed.
Imbedded in the colloid substance, but in very uncertun quantity, arc
corpuscles of peculiar form. According to Lebert (of whose description
and sketches I again gladly avail myself), they are chiefly these : —
(1) Nucleated cells lie free in the colloid substance, or enclosed within
large blood-cells, or grouped like an epithelium on the boundaries of the
alveoli or cysts. These, the so-called colloid corpuscles, are small, granu-
lar, moderately transparent cells, of irregular shape, from jtftjj to jn^m
* Fig. 113. Fibroai tiuuB of k colloid cancer oT Ibe bieaat. Magnified 70 time*.
t Bol the obMmtions of Dr. Jeonei (Proa, of Patbol. Sec., IB51.52, p. 333J make il probo-
bla that thcM are granulBj oT pfaoipfaaM of lime.
I LoKhka, in Tiichow'i Aicbir, it. 41 1. S In Tiicbow's Archir, it. 303
COLLOID OAITCIH.
of an inch in diameter, with email naclei or none. These are, probaUj,
cancer-cells hindered and modified in their development by the peoliil
circumstances of thnr formation ; for, with sach as these, more perfect
cancer-cells are Bometimes fonnd.
(2) Iiarge compound cells, mother-ceHs or brood-cells, which, in ty|»ei]
specimens (fig. 114 a, are from gj^ to g)g of an inch in diameter, ftrem
some instances Terj numerous. They are very pale, oral, round, or
tubular, and lie in cluBters : some of them display a lamellar sorfsot^
in^cated bj concentric boondary-lines ; and they enclose one large grv
nolar nucleus, or several of smaller size imbedded in their general gnna.
Jar contents, or, together with such nuclei, complete nucleated cells Iik>
cancer-cells.
(8) Large laminated spaces (fig. 114 b) are also found of nearly crystal-
line clearness, from ^ to yjj, of an inch in diameter. These are nsnally
oval and grouped, so as to form a soft parenchyma. Between the lamella
of their walls elongated nuclei are scattered ; in the interspaces between
them are clusters of small nucleated cells and nuclei ; and they enclose
brood-cells in the cavities surrounded by their concentric lamellae.
Whether we consider the larger, or the minuter, characters of this
colloid cancer, it seems difficult to believe that such a stmctnre can have
any close affinity with the cancers I have already described ; they appear,
at first sight, to have scarcely anything in common. Hence, some have
denied altogether the cancerous nature of this disease. But if we look,
not to its structure alone, but as well to its clinical history (so far as it
is illustrated by the great majority of the recorded cases), we shall find
ia it all the distinctive features of the cancers. Thus (1), its seats of
election are, remarkably, those in which the medullary cancers are, at
the same time of life, most apt to occur; (2) like the typical cancers,
the colloid infiltrates, and at length supersedes and replaces, by sabstitn-
don, the natural tissues of the afiected part; (3) like them, also, it il
prone to extend and repeat itself in lymphatic glands, the lungs, and
other parts near to or distant from its primary seat ;t (4) the colloid il
* Fig, 114. Suuc(or#( of colloid cancsr deachbed in the tttit From L«beit (Viicbcnr'*
Archiv. B. iv. Tsf. v.) and RDbiunskr (Deber die CyBte, TbT. vi.)
t Colloid CMicet Wka t:tku« nvAti^ li«d iu tan out of bIsvcd oms* Koordcd bjr L«b«n. t»
RELATIONS TO OTHBB CANCERS. 629
often associated with other forms of cancer, in the same mass, or in diffe-
rent tnmors in the same person ; (5) it appears as apt as any other form
to recur after removal ; (6) it may be derived, hereditarily, from a parent
having scirrhous cancer, or a parent with colloid may have offspring with
medullary cancer.
These facts seem enough to prove the right of including the colloid
with the generally received forms of cancer; certainly they are enough,
if we can explain the peculiarities of the colloid cancer as the result of
any known morbid process in Buch elemental structures as, in other con-
ditions, might have been conformed to the ordinary types of cancer.
And such an explanation is not impossible, for, as Rokitansky shows, the
colloid cancer has a near parallel in many cyst-formations in the normal
structures, and especially in those forms of bronchocele in which abun-
dant cysts, full of viscid fluid, are formed in the growing thyroid gland.
It seems, therefore, a reasouable hypothesis that the peculiarities of the
eoUoid or alveolar cancer are to be ascribed to cystic disease occurring
in elemental cancer-structures. Such a cystic disease may ensue in a
medullary or other cancer already formed ; but in the well-marked and
miformly constructed colloid cancer, it is probable that the deviation
to the cystic form ensues in the very earliest period of the cancer-struc-
tmres, while each element is yet in the nascent or rudimental state.
Snch may be the explanation of the structures of those cancers in
which the formation of cysts is carried to its maximum; and I have
reserved for this place an account of the various combinations of cysts
with cancers of all kinds,— combinations giving rise to many singularities
ef appearance, of which I omitted the description in earlier Lectures,
that I might once for all endeavor to explain them.
And first, we may divide these cases into those in which the cysts
are formed independently of the cancer-structures, and those in which
they are, or appear to be, derived from them.
In the first class we may enumerate many cases in which cysts and
euicers are in only accidental proximity. For example, a scirrhous
eancer may occupy part of a mammary gland, in the rest of which are
many cysts that are in no sense cancerous, or of which the chief lactife-
rous tubes are dilated into pouches or cysts (see page 490). And such a
omeer, in its progress, may enclose those cysts, and they may, I believe,
remain for a time imbedded in it. In like manner, the ovary, or any
other organ, being already the seat of common cysts, may become the
seat of cancer; and the too morbid structures may become connected
though not related.
• case by Dr. Warren (Med.-Chir. Trans., vol. xxvii.),'the multiplication was to an amount
■OBTcelj torpassed by any medullary cancers. It is true that it is not unfreqnently limited
to the stomach, or rectum, and the adjacent lymphatic glands; but it is equally observable
in the cases of villous and other medullary cancers, and I suspect is only an example of a
ganeral rule, that cancers (of whatever kind) on exposed surfhces are, on the whole, more
apt to remain single than those growing in other parts.
630 COLLOID CAItaBB.
In this class, also, may be reckoned the cases
from the vails of common cysts ; t. e. of cysts i
in cancer-etrnctnres. Thna medullary cancers i
the TiUons form, from the walls of ovarian cysts,
no cancerous appearance.*
There may be other methods in which, as by a
and cancers may thus become connected ; but th
pies. In the second class, including those in w)
be derived from cancer-structures, we find numert
be studied as a series parallel with those of the i
rouB cyst-formations in the natural structnreB,
(Compare Lectures XXII., XXIII., and page 8£
(a) Cysts filled with fluid, like serum variouf
general aspect resembling the common serous cyi
connected with cancers, especially with those of 1
grow quickly or to a great sixe. There may 1h
cysts, lying at the surface, or imbedded in the m
Sometimes, a single cyst of the kind enlarges so
of the cancer, exceedingly confuaiDg the diagnos
many cysts are formed, that the tumor appears i
of them, the cancerous structure only filling the i
close-packed walls.} Such cases tmght justly I
variety" of medullary cancer,
(6) Sanguineous cyata are found, as often as t
with the medullary and other cancers ; and the c
undergoes in them add not a little to the multi
that the cancerous masses may present.
(c) The colloid cysts hero find their type (page
structing the peculiar variety of cancer just d
mingled with ordinary cancerous growths ; for it
such growths, especially in the abdomen and
thickly viscid material, like mucus, or half-liqni'
ties of tint that we see in the cystic disease of t1
roid gland.
(d) While thus the principal varieties of simp
found in cancerous growths, as in the original tiss
so may we also trace in them the production of p
cysts from whose inner surfaces cancerous grow
with the glandular growths that may fill the cj
thyroid gland (page S5S). I have already often r
532, 587, &c.) ; and, now, need only add that su
are often to be found in the alveoli of the colloi
* Mu«eum or St. Banholomew'i, ixxi. SO.
t Btuch (Die DiaRnoTC der bdjaiiigen GeschwQIite, p. I) ;
% Mu>. Coll. SaiK^i^ll, 2'1'i, 'iSO, &c.; Mul St Bactbolomc
PATHOLOOT. 681
dayate, or flask-shaped, villous processes, like those formed in the early
stages of the dendritic vegetation of villous cancer (page 622), spring
from the wall of the alveolus. With laminated walls, and cancer-struc-
tures, or new cysts in their cavities, such villous growths crowded to-
gether probably constitute the structures'which I have described after
Lebert (page 628, fig. 113, c).* To less perfect endogenous growth we
must, 1 suppose, ascribe the cancer-structures which are found disorderly
mingled with the colloid contents of the alveoli.
Thus is the general anatomy of the autogenous cysts, which I described
m Lectures XXEL. and XXIII., paralleled in the cysts connected with
cancers. It may suffice to add that Rokitansky has traced a similar cor-
respondence in their origin and modes of development. The account of
the formation of cysts (page S36-3S8) might therefore be again read here ;
with the understanding that the nucleus, or smaller corpuscle, by whose
^ormous growth a cyst is formed, is here a cancerous element, while, in
the cases there cited, it was supposed to be an element of some natural
tissue. A part of the process is, moreover, already exemplified in the
instance of epithelial cancers (page 581, fig. 104-5) ; but in these, thd
cysts, produced in the shape of laminated capsules, are very rarely barren,
or filled with colloid substance.
Respecting the history of colloid cancer, the number of well-re'corded
cases, especially of those in which external parts were its primary seat,
b too small to authorize many general statements.
Lebert has shown, by his collection of cases, that it generally corre-
sponds with the history of scirrhous and medullary cancers; that the cases
are about equal in the two sexes ; that the greatest absolute frequency is
at the middle period of life ; that the disease is very rare in childhood ;t
that it is probably of somewhat slower average progress than the medul-
lary cancers ; that it more slowly affects the lymphatics and the organs
distant from its primary seat ; that, in general, its symptoms in each part
correspond with those of other cancers affecting the same part : and this
Bommary, I believe, includes all that can be prudently said upon the
matter.
* Compare Lebert^s figures with those of Rokitansky (Ueber die Cyste, pi. iT. fig. xvi.)
t Ha adduces two cases of children^ in which one was two, the other one and a half years
old. Mr. Eklward Bickersteth has observed two cases of colloid cancer of the kidney in
children, one of whom was 3^, the other 11, years old.
682 GENERAL PATHOLOaT OF CANCER.
LECTURE XXXIV.
GENERAL PATHOLOGT 07 CANCER.
PART L
CONDITIONS PRECEDING THE CANCEROUS GROWTH.
I PROPOSE, in this and the next Lecture, to consider the general patho-
logy of all the forms of cancer which have now been particularly de-
scribed ; to gather a general history of them from the statements made
concerning each ; and to trace how the laws observed by them correspond
with the more comprehensive laws of all specific diseases.
In the twenty-first Lecture (page 329) I stated the hypothesis whick I
think we must hold concerning cancers: namely, that they are local
manifestations of certain specific morbid states of the blood ; and that in
them are incorporated peculiar morbid materials which accumulate in
the blood, and which their growth may tend to increase.
In the terms which are more usual in discussions respecting the nature
of cancers, I would say that a cancer is, from the first, both a constitu-
tional and a specific disease. I believe it to be constitutional, in the
sense of having its origin and chief support in the blood, by which the
constitution of the whole body is maintained ; and I believe it to be
specific, 1st, in the sense of its being dependent on some specific material
which is different from all the natural constituents of the body, and diffe-
rent from all the materials formed in other processes of disease ; and
2dly, in the sense of its^presenting, in the large majority of cases, struc-
tures which are specific or peculiar both in their form and in their
mode of life.
The evidences for this hypothesis appear in the conformity of cancer
to the other specific diseases, for which a similar hypothesis is nearly
proved (Lect. XX.), and in the fitness of the terms which it supplies for
the general pathology of cancer.
I will speak in this lecture of the conditions that precede the forma-
tion of a cancerous growth, and in the next of the growth itself.
The general history of cancers, and their analogy with other diseased
that are, in the same senses, specific and constitutional, imply that, be-
fore the formation of a cancerous growth, two things at least must co-
exist : namely, a certain morbid material in the blood, and some part
appropriate to be the seat of growth incorporating that material, some
place in which the morbid material may assume, or enter into, organic
structure.
The existence of the morbid material in the blood, whether in the
CONDITIONS PRECEDINQ CANCEBOUB GROWTHS. 688
rndimental or in the effective state, constitutes the general predisposition
to cancer ; it is that which is, by some, called the predisposing cause
of cancer. The morbid material is the essential constituent of the
'^cancerous diathesis, or constitution:" and when its existence produces
some manifest impairment of the general health, independently of the
cancerous growth, it makes the '' primary cancerous cachexia" (see
page 522).
That which evidently makes some part of the body appropriate for
the growth of a cancerous tumor is a so-called excitiug cause of cancer ;
but it is a cause of cancer only in so far as it fits some part for the local
manifestation of a disease which already, in its essential material, exists
in the blood.
It seems very important to keep constantly in view that these two con-
ditions must coincide before the appearance of a cancerous growth;
important not only to recognise their existence, but, if we can, to mea-
sure the several degrees in which, in each case, they are present ; because,
upon our recognition of the shares in which they respectively contribute
to the production of the cancerous tumor, must depend the chief prin-
ciples of practice in relation to the removal of such tumors. The larger
ibe share taken by the constitutional element of the disease, — that is,
bj the cancerous condition of the blood, — ^in the production of a cancer-
ous growth, the less is the probability of advantage to be derived from
the removal of that growth ; while, on the other hand, the more largely
the local state enters into the conditions upon which the cancerous growth
18 founded, the more benefit may we anticipate from the removal of the
cancer and of the locality with it.
So, too, in our considerations of the mere pathology of cancerous dis-
eases, it seems essential to have a just regard of both these previous
conditions. If we look at only a certain class of cases, we may easily
find enough to persuade ourselves that cancers are, from the first, and
throughout their course, wholly constitutional diseases ; or, if we look
exclusively at another class, which are as truly cancerous as the first (ac-
cording to any natural definition of the term), we may find equal evi-
dence for believing that they are, at least in the first instance, entirely
local diseases, and that the constitutional affection which may attend
them is only something consequent upon their growth.
When, for example, wo see that certain organs are much more liable
than others to the growth of cancer, and that, in those organs, the growth
sometimes follows the infliction of a local injury, or some previous dis-
ease; and much more when we see, as in the case of the scrotal epithe-
lial cancers, that the repeated application of a stimulus, such as soot, to
a part of the body, will lead to the formation of cancer in even a large
number of persons, wo might assume that the growth has its origin
wholly in the local state, and that whatever may follow of disease in
other parts is only the consequence of the growth. On the other hand.
634 OSHBBAL PATUOLOOT OF CANOSE.
when we consider the namerons analogies between cancers and the ad-
mitted specific blood-diseases ; when we see the rapidity of outbretk
with which cancerous disease sometimes manifests itself in mnltipk
growths, apparently irrespective of the locality in which they are pro-
duced, and how, sometimes, a distinct affection of the general healdi,
intense and destructive, exists even while the cancerous stmctore is yet
trivial or unobserved ; and when we see the insufiSciency of all loeil
causes to excite the growth of cancer in some persons, we might suppose
that the cancerous disease is one wholly constitutional, wholly dependent
on some morbid condition of the blood, and that the formation of the
tumor is but as an accident of the disease, and is independent of the
state of the part in which it occurs.
It is in correspondence with these classes of cases, too partially eiir
mined, that two distinct opinions are commonly entertained respectmg
the nature of cancer : some holding that it is from the beginning, aod
throughout, a constitutional disease ; and others, that it is, in the first
instance, if not through its whole course, a local one. The reconcilia-
tion, not only of the two conflicting opinions, but of the seemingly con-
flicting facts upon which they chiefly rest, is to be found in this, — that
the complete manifestation of cancer — ^the formation of a cancerous
growth — ^is suspended till such a time as finds both the constitutional and
the local conditions co-existent, — till the blood and the part are at once
appropriate.
I might show how consistent the belief of the necessity of this coind-
dence is with what is known of other specific diseases (as illustrated in
preceding lectures). But let me illustrate it by two cases, such as may
frequently be met with. Bruch* records the following : — ^A woman had
a child at eighteen years of age. The child died when it was a month
old, and her breasts were left to the disturbance which usually ensues in
prematurely arrested lactation. At the age of thirty-four she received
a blow on the right breast. This was followed by no manifest change of
structure, but, for some days, by severe pains, and then, for a much
longer time, by feelings of swelling and tension at the menstrual periods.
At thirty-nine she received another blow upon the same breast, which
was followed by an increase of pain. Soon afterwards she was exposed
to cold, and then there ensued erysipelatous inflammation of the breast,
followed by induration of a part of the mammary gland. This, however,
continued without change for four years ; but then, after menorrhagia,
a tumor appeared in the breast. When this was removed, or partially
removed, it was found to be not a cancerous, but a cystic tumor, with
growths from the interior surfaces of the cysts. She remained well after
this, the wound having perfectly healed, for twelve years more, and in
this interval she ceased to menstruate; but now, when she was fifty-five
years old, after having a whitlow and inflamed lymphatics of the right
* Die Diagnose der bosartigen Ge«cbwQl»te, p. 04.
LOCAL AVD COXSTITUTIOKAL PRBDISP08ITI0N8. 685
TtDy another tumor formed in the breast, which had every appearance
f being cancerous. It was removed ; but it recurred, and ended fatally.
Now, surely, in such a case as this, we may say that all the local con-
litions necessary for the production of a cancer of the breast had been
inply provided. They had existed, or had been reproduced from time
0 time, for a period of upwards of twenty years ; yet, being alone, they
lad been insixfficient ; and no cancer appeared till the time when, at a
Bore favorable condition of age, the cancerous condition of the blood
ras manifested, and filled up the measure of the necessary precedents of
be disease.
Contrast with the cases of this kind those to which I had occasion to
ofer in a former lecture (page 552), and of which I may here repeat
ne. A boy received a cut in his eye, which had been previously sound.
Hthin three weeks of the injury a fungus protruded from the eye. It
VB removed with the whole eyeball and the contents of the orbit. The
'ound had scarcely healed before a fresh growth appeared ; and shortly
fterwards the boy died with medullary disease extending from the orbit
> the brain. We can scarcely express such cases as this in any other
mns than that the cancerous condition of the blood existed at the time
f the injury, but was insufficient for the production of a cancerous growth,
nd remained latent, for want of an appropriate locality for the growth,
ill the injury, disturbing or causing the suspension of the natural course
f nutrition in the part, supplied the appropriate local condition. As
ne might say, the seed had been long present in the blood, but the soil
w wantmg, and the injury, hindering or diverting the eye from its
rdinory nutrition, suppfied the want, and prepared the soil for the growth
f the cancer.
These cases, I repeat, are but examples of classes. In the one class,
ne seem to meet with all the constitutional or blood-conditions of cancer-
08 disease complete, .waiting only for the existence of some part in
iiich the cancerous growth may be manifested ; in the other class, the
XMd conditions are abundantly present, but the disease does not appear
in the cancerous condition of the blood is complete (compare p. 318).
It may, further, be deduced from these cases, in which the extremes
Instrate the ordinary mean, that if either of the two conditions be pre-
BDt in an extreme degree, its intensity may compensate for a compara-
ire defect of the other. Among the cases to which I have been refer-
ing, we find certain in which the cancerous disease makes its appearance
1 snch a multiplicity of growths and of parts, that it seems indifferent
> local conditions ; and these are the very cases in which all the other
onstitational characters of cancer are most strongly marked ; in which
ftchezia often precedes the growth, and in which the removal of the can-
er interferes in no way with the progress of the constitutional disease,
nlesB it be to accelerate it. On the other side, we meet with cases in
Uch the long-continued irritations, or frequent injuries' of certain parts
686 OBNBBAL PATHOLOOT OF OAlTOBm.
\
\
\
of the body, seem almost sure to be followed by cancer ; and these m \
the cases in which the constitutional characteristics of the disetie m - ^
least marked, and in which, as in epithelial cancer of the scrotmn tad of f
scars, we may hope that the recnrrence of the disease may be long dc» f
ferred, if that which has first appeared be removed with its seat. In tUi f
class of cases it may be said, the cancerous blood-condition is S(i slovlj }
developed, that the cancerous growth can ensue in none bat a pemliarij |
appropriated part, which part being removed, the growth is for a tia^
or for life, impossible ; while, in the former class, the blood-conditioD ii
so highly developed, or so intense, that almost any part suffices for the
seat of growth.
Let me now proceed to consider what each of these conditions, necci»
sary as precedents of the growth of a cancer, consists in. What is tki
cancerous condition of the blood ? and what is the state of a locality spl
for the formation of a cancerous growth ?
I. Concerning the state of the blood, our positive knowledge is vcrj
trivial and obscure ; perhaps it would be safest to say that we hare m
present none. We may be sure, on grounds to which I have already i^
ferred, that there is a peculiar material in the blood which is sepantcA
from it, and constantly renewed, in the formation of a cancer; b«t vt
can say what this material is not, rather than what it is.
We may reasonably hold that, in cancerous persons, the whole coo!ti-
tution of the blood is not perverted ; for we see that all the tissues wlj
for a long time be perfectly nourished, even while the cancer is tnakiiif
progress ; that injuries may be repaired with the ordinary quickness sal
perfection ; that the products of inflammation may be like those in not-
cancerous persons, and may pass through their ordinary development!;
and that some other specific diseases may have their usual course. It
would therefore be unreasonable to regard the whole of the blood of s
cancerous person as perverted from its normal condition. The cancerooi
state is not a total change of the blood, but depends, probably, on Moe
definite material mingled with the natural constituents : and this mlt^
rial, we may believe, is derived from a morbid transformation of one or
more of the natural constituents of the blood, and is maintained, as mat-
hid structures are, by the persistence of the same method of transforma-
tion, or by its own assimilative force.
But now, as to what this material is ; or, again, is not. I believe it if
not anything visible to the sight. There is not, so far as I know, anj-
thing in the blood of a cancerous person which we can recognise as a can*
cer-structure. There are no cancer-cells, nor, in any form, visible germs
of cancer, existing in the blood, and only needing to be separated from
it to make up or grow into the cancerous structure. In advanced casef
of cancer, and especially in those in which the cancerous substance is
very softened and broken, we may meet with portions of it in the bloodi
IVOOMPATIBLB DI8EABS8. 687
vhich appear as if they had been detached or absorbed from some growth,
and carried on with the stream. In similar cases we may find cancerous
formations in the blood itself. Such seem to be some of the cancerous
growths in the. veins and the right side of the heart. For, although,
among the former, there are many in which the growth has only extended
into 0ie veins, through their walls involved in cancerous tumors, yet there
are others in which, as in the endocardial cancers, the internal growth
takes place far from any other tumor. In these we may believe that
cancerol^) structures have been conveyed in the blood to the part of the vein,
or of the right side of the heart, at which they have been arrested,
and to which adhering (either alone or with blood-clot), they have sub-
sisted and grown on materials derived from the passing blood. But none
of these cases afford any support to a belief that, previous to the exis-
tence of a cancerous tumor, any visible germs of cancer exist in the
Uood.
Other means for investigating the very nature of the cancerous mate-
rial in the blood seem as impotent as the sight. Minute chemistry has,
up to this time, done nothing ; neither can we yet accept, I think, that
which is in part a chemical theory, and has been especially held by the
pathologists of the Vienna school, — ^namely, that particular diatheses or
dyscrases of the blood, appropriate to such diseases as cancer and
tubercle, may be recognised by a superabundance of albumen or of fibrine.
The facts adduced as bearing directly on these doctrines are, at present,
few and incomplete ; and although the course of investigation, in which
thej have been observed, is the most hopeful yet entered upon, I think
they are not su£Scient either to establish the theories based on them, or to
outweigh the general improbability, that diseases so complex as cancer
and tubercle should depend, chiefly, on quantitative variations in any of
the larger constituents of the blood. Neither can it, I think, in the pre-
aent state of organic chemistry, and with so few analyses as we yet pos-
sess of the blood of cancerous and other diseased persons, be more than
a guess, that either cancer or any other such specific disease, depends, in
any sense, on qualitative modifications of the albumen, or the fibrine, or
any other single constituent of the blood.
At present, I believe, the best part of the facts established, or made
probably, by these investigations, relate to the antagonism or incompati-
bility of cancer and certain other specific diseases. I think we cannot
doubt that, as a general rule, cancerous and tuberculous diseases do not
make active progress at the same time ; and that, in this sense, they
exclude one another, and are incompatible. I mentioned in a former
Lecture (p. 837), a striking case bearing on this point, in which, as it
seemed, the rare event of arrest and almost complete recovery from scirr-
hous cancer was connected with the evolution of tuberculous disease. I
believe, also, that I have seen at least one instance in which active tuber-
culous disease of the lungs was arrested immediately before the appear-
688 GIKBRAL PATHOLOOT OF OlVCBl.
ance of a scirrhous cancer in the breast ; and we find, in so manj of thoii
who die with cancer, the remnants of tuberculous disease from wUdi tkj
have suffered in earlier life, that we may belieye that the reooferj bm
the one has been in some manner connected with the sapenrentioii of tb
other. So, on the other side, the rarity of progressive tuberculous dismi
in those that are cancerous may be because, except in sudi ezmaMiy
rare cases as that to which I have referred, the caneeroos diatbenso-
eludes that condition of the blood in which the tubereukms dimsi ki
its rise.
To the same class of facts, as illustrating the exclusion of one morW
condition of the blood (or, as Hunter would have said, of one morU
action), by another, we may perhaps refer the occasional withering of i
cancer under the influence of some fever, and the more rarely oecorrnf
complete death of one, so that during an attack of acute fever the whole
mass may slough off ; and this whether the feverish condition of tk
blood be produced by some miasma, or by medicinal means. Sack I
fear, is all that can be, at present, safely regarded as matter of bet a
relation to the nature of the peculiarity of cancerous blood ; and it mm
be admitted that these facts are scarcely more than indications of tk
direction in which inquiry should be made. Let us next see if we eu.
in any measure, trace the method of its production ; — ^whence the spcdfc
material is derived from without, and the conditions most favorable to id
generation within, the body.
First, it is evident that a disposition to cancer may be derived bj
inheritance ; that something may be transmitted from the parent to tlw
offspring, which shall ultimately produce both the cancerous conditioii of
the blood and the locality apt for the cancerous growth.
The proportion of cases in which this hereditary transmisnon is masi-
festcd is, it is true, but small. In 160 cancerous patients, there were
26, or very nearly one-sixth, who were aware of cancer in other memhm
of their families (see pages 514, 552). The proportion may seem too
trivial to reason upon, yet it is larger than could be due to chance (pace
593) ; and its import is corroborated by the fact of so many membm of
the same family being in some instances affected.
That which is transmitted from parent to ofispring is not, stricth
speaking, cancer or cancerous material, but a tendency to the prodnctios
of those conditions which will, finally, manifest themselves in a caneenw
growth. There are here some facts worth dwelling upon, both for their
own sake, and because they are clear instances of the manner in wbicb
the hereditary transmission of the properties of the parent body take*
place.
I repeat, that which is transmitted from parent to offspring is not can-
cer itself, but a tendency to the production of cancer at some time bi
future from the birth. We have no reason to believe that a eanccro«
material passes with the germ. To suppose such a thing, where the csn-
HBBBDITABT TBANSMISSIOIT. 689
eeroiiB parent is the male, would be almost absurd. Moreover, no reason
to believe that cancerous material passes from either parent is furnished
hj any frequency of congenital cancer, or (so far as I know) by cancer
bdng earlier developed in the oflbpring of cancerous parents than in other
persons.
• But whfle, on the one hand, we cannot assume that a cancerous mate-
rial passes with the germ or impregnating fluid ; on the other, we cannot
imdeiBtand the transmission of a tendency or disposition to any event,
independently of all material conditions. The germ from the cancerous
parent must be already, in some condition, different from one from a
parent who is not cancerous, if, in the course of any number of years,
cancers are to be formed out of the substance which the germ, in its
development, or subsequent changes, will appropriate. Our expression,
ihen, may be, that in the impregnated germ from a cancerous parent,
one or more of the materials, normal as they may seem, are already so
&r firom the perfectly normal state, that after the lapuse of years, by their
development or degeneration, they will engender or constitute the can-
cerous material in the blood, and, it may be, the locality apt for a cancer-
OOB growth. *
: But now, let it be observed, this tendency to cancerous disease is most
commonly derived from a parent who is not yet manifestly cancerous ;
for, most commonly, the children are born before cancer is evident in the
parent ; so that, as we may say, that which is still future to the parent
is transmitted potentially to the offspring. Nay, more : the tendency
which exists in the parent may never become in him or her effective,
although it may become effective in the offspring : for there are cases in
which a grandparent has been cancerous, and although his or her children
liave not been so, the grandchildren have been. How admirable a dis-
covery it would be if we could find the means by which the tendency, con-
veyed from the grandparent to the child, was yet diverted from its course,
even after it had been transmitted to the germ of the grandchild !
• Let me repeat, the cases of hereditary cancer only illustrate the com-
mon rule of the transmission of hereditary properties, whether natural or
morbid. Just as the parent, in the perfection of maturity, transmits to
the offspring those conditions, in germ and rudimental substance, which
dudl be changed into the exact imitation of the parent's self, not only in
the fulness of health, but in all the infirmities of yet future age ; so, also,
even in seeming health, the same parent may communicate to the mate-
rials of the offspring the rudiments of yet future diseases ; and these
rudiments must, in the case before us, be such modifications of natural
compositions as, in the course of many years, shall be developed or dege-
nerate into materials that will manifest themselves in the production of
cancer.
There is, surely, in all science, no fact so strange as this : and it need
not be a barren &ct, fit merely for wonder and vain speculation ; for we
may deduce from it that the cancer-substance in the blood, whatever it
640 OENIRAL PATnOLOaT OP CAHCBB.
may be, and whencesoever derived, is a result of long-continaed cUbnri-
tion ; needing, as the normal materials of the body do, to pa.<9 throa;:h
a life of continual change before it attains its complete efficiencv. Tht
period reqiured for this completion of the cancer-material, is the time,
often of long delay, during which the disease, according to vari<ias ex*
pressions, is 'latent," or only ^' in predisposition.** But such vxfu*
sions are deceptive. As with other specific blood diseases, so with caa-
cer, the predisposition to it is a substantial thing ; and we should hoM
that, in all the time of latency, there is that thing in the blocMl, which
will become, or generate by combination, the effective cancer-miteniL
unless (as in the healthy generation between the cani^crous grandparan
and the cancerous grandchild) it be destroyed or retained in the counc
of natural nutrition.
In hereditary transmission, the cancer-material may be so moiiified.
so that the form of the disease in the offspring may be different fr.'O
that in the parent. The change from scirrhous to medullary canoY.
and vice versdj is, I believe, not rare. I have mentioned casM of
alternation between these and the epithelial cancers (page Si^i): and
a case of melanoid cancer in a patient descended from one with a
scirrhous breast (page 608.) Mr. Simon has told me that he removed a
colloid cancer from the cheek of a woman whose child, seven vean
old, was dying with medullary cancer of the eye ; and M. Leber,
with two cases like these, relates that the celebrated Broussais died with
medullary cancer of the rectum, and his son, Gasimir, with cidloid cuoer
of the same part. With so many eases supporting it, this kind of trans-
mission of cancer can hardly be <Ioubted. But, I believe, we mav trace
further changes in the transmission ; and that the material may be «
altered that, as we may say, the cancerous disposition may gra4liuiij
cease, or fade out in the production of tumors, whose characters are ia-
termediate or transitional between cancers and simple growths. I hare
referred (pages 431, 474) to cases illustrating this opinion ; and I f«I
sure that many more will be found ; for we may observe corre:iponJi!.:
changes, in both form and degree, in the hereditary transmission of manj
other diseases. Thus the syphilis of the infant is seldom exactly iik*
that of the mother ; the same family may include cases of insanitv, epi-
lepsy, palsy, chorea, stammering, and other diseases allied to these in
that all arc affections of the nervous centres, but differing from them ii
form and degree.*
The rule of hereditary transmission (a rule which, like many in patho-
logy, has more seeming exceptions than examples)! holds for only a
sixth of the cases of cancer. Can we, for the rrmaining five-sixths
trace any external source of the morbid condition of the blood ? Inocu-
• Hcrodimry mn I formations dinplny similar mutations in trantiiu ; as in inftanr^i in iL*
Maseum of St. Bnrtholomew^is Casts A 21 to 27. The whole of this sul>icri of ihedAr^e
of cliiitlM»f.is on heniditary transmission will repay, I believe, I'jedeepesi itadr
t Page a07. "^ '
INOCULATION. 641
Itttion and contagion are the only probable sources of the kind ; but con-
cerning these the presumed facts are, at present, very few and uncertain.
There are cases in which, by the inoculation of cancerous material
into the bodies, or by the injection of such material into the blood, of
dogs, cancer has seemed to be produced. I think that, in a large num-
ber of experiments, that result has been three times obtained ; but it is
quite possible that the dogs used for these three experiments were can-
cerous before the human cancerous matter was injected into them ; for
eancer is indeed a frequent disease among dogs. The instances are cer-
teinly too few for proof of inoculation.
There are, also, certain cases in which it seems possible that cancer
may have been transmitted from the wife to the husband during the act
of copulation. Such cases are recorded by Dr. Watson and Dr. Copland :*
wives haying cancer of the uterus had husbands with cancer of the
penis. Of course, it must be questionable whether there were in these
eases more than the accidental coincidence of persons having married,
in both of whom an ordinary and independent generation of cancer
ensued ; and we cannot conclude that inoculation of cancer may thus
oocnr, unless it should appear that persons thus related become cancer-
ens in larger proportions than they do who, being otherwise in similar
eonditions, are not thus exposed to the possibility of inoculation.
Again, I have heard that cancerous matter having been inoculated
under the skin of frogs, cancerous growths have been produced in them.
I have repeated this experiment, but without effect ; for all the frogs in
whom I inserted the cancerous matter died soon after. But the facts,
80 far as I have yet heard them, have not much meaning in relation to
the general pathology of cancer ; for I believe it is not yet proved that
the local growths of cancer, which are the consequence of the inocula-
tion, are followed by general cancerous disease, or by the production of
cancer of distant parts, as well as in that in which the matter was depo-
sited. Unless this occurs, the experiments only prove the fact (and a
Tory strange one it is) that materials of disease from human bodies,
being inserted in the bodieis of cold-blooded animals, will live and grow,
even upon the materials of the cold-blooded creature. In like manner,
if any one could establish the supposed cases of husbands inoculated by
their wives, he might only prove that cancerous elements may subsist
and increase upon other materials than those of the body in which
themselves were generated. Unless the cancers thus generated, in the
first instance locally, are found to multiply themselves in distant organs,
these cases of isolation will prove no more than that cancer, like a para-*
sitic growth, may be transplanted, and grow on common or indifferent
nutritive material ; they will have no bearing on the questions concerning
the nature and origin of cancerous blood.
At the most, then, we may assume that a transference of cancer by
* Diet of Pract Med. ; Art. Soirrhoui and other Tumors.
41
64S GENERAL PATHOLOGY OF CANCBl.
inoculatioii is possible. But such an assumption will not mitcriallj
diminish the number of cases in which we look in vain for anv ext«nial
m
source for the disease, and in which all that we can study are the cona-
tions most favorable for its production within the body. Of the^e o.Dit
tions I have already spoken, in relation to each of the principal f^rai
of cancer. I need, therefore, do little more than sum up the genenl
conclusions concerning them.
First, respecting the influence of sexual peculiarities. Women are. «a
the whole, more liable to cancer than men are ; but in what proponioa
they are so cannot be exactly stated ; Lebert assigns about 37 per cent.
as the proportion of cancers in males : Dr. Walshe finds it scareely mtn
than 26 per cent. This is just one of the points on which the truth vil
not be known till statistics are collected by practitioners under vkme
charge the two sexes, and all the organs of each, fall in just proportioai^
and by whom the existence of internal cancers is as consuntly ascc^
tained by autopsy as that of external cancers. The frequency of caactr
of the breast and uterus gives an apparently large preponderance of
cases in women ; but, on the other side, the cancers of the skin, bo&e^
and digestive organs, greatly predominate in men. The liability of tkt
breast makes scirrhous cancer by far most frequent in women ; bat tUi»
in a general estimate, may be nearly balanced by the preponderance of
epithelial, osteoid, and villous cancers in men."*"
The influence of age may be more definitely stated. Dr. Wal5be htf
clearly shown that ^^the mortality from cancer*' [i. e. the number of
deaths in proportion to the number of persons living] ^^ goes on stcadiij
increasing with each succeeding decade until the eightieth year." Uii
result is obtained from records of deaths ; but it is almost exactlr cos-
firmed by the tables I have collected, showing the ages at which the can-
cers were first observed by the patients, or ascertained by their attendanti
In 772 cases, including cancers of all kinds, the ages at which thej ip-
peared were as follows : —
Under 10 yean 27
Between 10 and 20 *• 30
20 and 30 « 78
" . 30 and 40 •* 130
*» 40 and 50 •* 300
" 50 and 60 »* 153
" 00 and 70 " 98
70 and 80 « 57
The proportions between these numbers and the numbers of persons
living at the corresponding ages (calculated in the same manner as in tk
previous Lectures, pp. 518, 551, 592), will show the proportionate f^^
quency of cancer at each period of life, and may be represented by ikf
following numbers : —
• The particular influences of sexual difference may be collected from pp. 512, :»50. 5?i.
608, (W8. On all the questions capable of being solved bjr statiaticai the largwi infc
if collected by Dc. VTaVtUe.
INFLUBNCB OF AGE. 648
Under 10 years 5
Between 10 and 20 years 6*9
" 20 « 30 " 21
« 30 « 40 " 48-5
" 40 " 50, « 100
« 50 « 60 « 113
« 60 " 70 « 107
« 70 " 80 « 126
Thus the liability to cancer seems always increasing from childhood to
eigh^ years of age. A single exception to the rule (between 60 and 70)
appears to exist ; but this would very probably not appear in estimates
from a larger number of cases. The general fact, and that of the im-
mense increase of cancer after 40 years of age, are of exceeding value in
preying that it is a disease of degeneracy. *
Within this larger rule, others may be collected from the foregoing
Lectures. Of the three chief forms of cancer, the medullary alone exem-
plifies the rule of frequency constantly increasing from earliest to latest
life ; but the rate of increase is, of course, different from that shown iii
the general table (p. 551-2). The epithelial cancers exemplify the rule
after the age of 20 ; before that age they are scarcely found (p. 592).
The scirrhous have their maximum proportionate frequency between 40
and 50* (p. 518). The melanoid cancers are nearly conformed to the
rule of the medullary. The osteoid and colloid probably have rules of
frequency peculiar to themselves, and depending upon local conditions :
but we need more cases to calculate them.
The increase of frequency of cancer with increasing years, its great
prevalence after middle age, and the conformity to this rule shown by
medullary cancers which are least of all dependent on locality for their
development, — these facts may prove, as a rule, that cancer is a disease
of general or constitutional degeneracy. But, as in every other part of
the pathology of cancer, so, in estimating the influence of age in its pro-
duction, we must consider the effect of time in making certain parts apt
to be the seat of cancer. Such an effect is shown in the different liabili-
ties which each organ manifests at different periods of life. These cannot
be exactly stated ; but, beyond doubt, the eye and orbit are earliest apt
to become cancerous ; then the bones, testicles, and the cellular tissue of
the limbs and trunk. These are its chief seats before 80 years of age ; from
80 to 50 it predominates in the penis, uterus, external sexual organs, and
the breasts ; after 50, in the integuments and digestive organs, f I fear
nothing can be said of the real nature of the changes ensuing in each
organ, which thus make it, at different times of life, more or less appro-
* It is probably due to this great frequency of scirrhouf cancer in the female breast tliat
(aa Dr. Walthe found) the increase of mortality from cancer between 40 to 50 is so much
giaatar m women than in men.
t More rules of this kind may perhaps be gathered from the statistics of Walshe and
Lebert ; but with caution, for want of such records as I have said are necessary to estiuHile
Ae liabilities of the sexes.
644 GBNBRAL PATHOLOGT Of OAHCBB.
priate for the seat of cancer. In some parts, as the testicles and limbs,
the chief liability seems to coincide with the first attainment or mainte-
nance, of full functional power ; in others, it falls in with the beginning of
the loss of power, as in the uterus and breast.
Two other conditions seem to have influence in producing or promoting
the cancerous constitution : namely, climate, and mental distress. Dr.
Walshe has collected evidence that ^^the maximum amount of cancerous
disease occurs in Europe," and that it is very rare among the patients of
the hospitals at Hobart Tqwn and Calcutta, and among the natives of
Egypt, Algiers, Senegal, Arabia, and the tropical parts of America. We
cannot, indeed, be sure that this difference depends on climate ; it mij
be due to the national differences in habits of life ; possibly, as Dr. Wabhe
suggests (p. 415), the greater prevalence of cancer may be due to the
more wasting influence of the higher state of civilization. More records
are necessary to decide such questions ; and it may be well if they in-
clude accounts of the apparent varieties of cancer among nations whoee
climate and habits of life are not materially different. (See pp. 545,
598.)
It is only on a general impression, not by counted facts, that we can
reckon deep mental distress among the conditions favorable to the pro-
duction of cancer. I do not at all suppose that it could of itself generate
a cancerous condition of the blood ; or that a joyous temper and prospe-
rity are a safeguard against cancer ; but the cases are so frequent in which
deep anxiety, deferred hope, and disappointment, are quickly followed
by the growth or increase of cancer, that we can hardly doubt that
mental depression is a weighty addition to the other influences that favor
the development of the cancerous constitution. Nor is it strange that it
should be so ; it is consistent with the many other facts showing the
affinity between cancer and depressed nutrition.
But, after all, when we have assigned to these conditions their fall
weight in producing the cancerous constitution or state of the blood, that
which may strike us most of all is the comparatively small influence which
any known internal or external conditions possess. We are, as yet,
wholly unaware of any great difference, in the frequency of cancer,
among those of our own nation who are most widely apart from each other
in all the ordinary conditions of life. The richest and the poorest alike
seem to be subject to it; so do the worst and the best-fed; those that are
living in the best conditions of atmosphere, and those that are immured
in the worst ; those that are cleanly, and those that are foul ; those of all
temperaments, and of all occupations (except such as have peculiar local
influences) ; those that appear healthy, and those that are diseased, ex-
cept those with some few specific diseases. We can hardly lay our hand
upon any one of the various circumstances of life, in the various orders
of society in this country, to which we can refer as rendering one more
or less liable than another to the acquirement of the cancerous constitution.
IN0REA8B OF DIATHBBIB. 646
Dr. Walshe's evidence amply shows the want of foundation of all the
general impressions opposed to this conclusion.
From this confession of ignorance respecting the production of the
cancerous constitution, or, as I would say, of the cancer-material in the
blood, when it is generated within the body, I will proceed to speak of
some of the changes which, being once generated, it may undergo.
In all ordinary events the normal course of cancerous disease is that
of steady increase, steady progress towards death. The increase is indi-
cated by two different, but usually commensurate, series of phenomena :
those, namely, of increasing formation of cancer-structures, and of in-
ereaaing cachexia.
We may commonly observe, that, from the beginning of a cancerous
formation, there is a constant increase in its mass, and in the rate at
which it is added to. Even the cancers that are, in part, ulcerating, are
usually growing, at a greater rate at the border or surface opposite to
that in which ulceration is destroying them ; or else, while ulceration is
going on in one cancer, there is a greater rate of increase in others ; or,
the number of growing masses is constantly increasing. In one or more
of these methods most cases exemplify the general rule, that the quantity
of cancer which is formed, within any given length of time, regularly
mcreaaes from the beginning to the end of the case.
In most cases the increasing formation of cancer is accompanied by
manifest indications of increasing cachexia. But it is not always thus ;
and, on the other hand, we find ca«es in which the cachexia increases
without proportionately increasing cancerous formations: cases in which
we may say that the cancerous condition of the blood manifests itself
less plainly in the production of growths, than in its interference with
Ae ordinary phenomena of life. Such cases are not unfrequent among
those of cancer of the rectum : we see the patient intensely ill, and
dying with cachexia, to which the extent or rate of growth of the can-
cerous tumor bears no proportion. So, sometimes, with cancer of the
lirer; the cachexia is quite disproportionate to the amount of cancerous
formation, and to the degree in which it interferes with the functions of
the organ. In these cases, the cancerous disease exemplifies a frequent
erent in the history of specific diseases : namely, that when the morbid
material is most intense and acute in its action, when it most manifestly
affects the constitution, it may produce the least indications of local mor-
bid influence. •
In both these sets of cases, the increase of cancerous disease, and its
accelerating rate, are illustrated as the rule of its career. The pheno-
mena, in the first set of cases, may be explained by assuming that the
quantity of cancer-material in the blood regularly increases ; those in the
second, that, with its increase, it undergoes some transformation, render-
ing it less appropriate for growths, but more injurious to the other offices
of the blood«
646 OBNBRIL PATHOLOQT Of 0
(6.) The cancerous conatitntiott ma; apparent]
ready formed may maintain it«elf, subsisting, pi
constituents of the blood,* but its progressive i
time suspended. I hare exemplified this by cat
(p. 653), of which the general hbtory was, that, t
increase, the tumors ceased to enlarge, were for
general health also remaining the same), and then
mode of progress.
(c.) The cancerous constitution may be in son
modified. It may manifest itself for a time in a
and then in some other form. Thus scirrhous ca
in secondary growths, by medullary cancer ; ostf
vice ven& ; and I think, epithelial by medullary,
these oases assume a transformation of the speci£
the blood — a change corresponding with that wli
larly traced in the materials of other specific dii
in their successiye stages or periods of life (pp. 3<
Lastly, the cancerous diathesis, even after it 1:
growths, may be superseded. Thus we may ei
retrocession, of cancer, when tuberculous disease
In the last three events the rule of progress in (
But if we could reckon all the cases in which any
they would make but a few exceptions to the gen
cerouB constitution regularly increases at an acc(
little change in its methods of manifesting itself.
I pass now to the consideration of the second
a cancerous growth, namely, the existence of so)
Beat, some apt locality. Such fitness may be na
in parts in which it is in some measure natural, i
accident or disease.
Certain parts of the body are evidently, and in
influences, far more liable than others are to bec(
They are, thus, naturally apt localities ; not equ
but usually becoming so at certain periods.
We have no such full and impartial statistics
able us to state clearly the proportions in which
primarily or secondarily aftccted with cancer,
believe, no large statistics on which we can place
determining this point : bills of mortality, found
confirmed by autopsy, and the records of those i
medical or chiefly surgical, supply only unsafe or
• I shall revert id iliis poini in llie next [ectmt. The mair
niHiniaineit ; once formed, B caireer, like any oilier lumor, ma;
LIABILITIES OF OBBTAIH PABTCL 64T
It cannot be doubted that the uterus, stomach, and female breast hold
the first place in aptness for primary cancerous growths ; and the lym-
phatics, lungs, and lirer, for secondary growths ; and that among the
parts least liable to either affection are, the spinal cord, tendons, tonsils,
pharynx, and prostate gland. But beyond these general statements, none,
I think, can be safely made. Neither does any explanation yet offered
of the different liabilities of parts seem well founded. As Dr. Walshe
observes, all that has been said to explain the liability of the breast and
QteruB may be equally well said of the ovaries, which are comparatively
rarely cancerous. So, too, what has been said about the brain and
stomach, and testicle, is just as applicable to the spinal cord, the duode-
num, and the epididymis ; yet these parts of similar systems are, seve-
rally, in complete contrast in their aptness to be the seat of cancer.
It seems impossible, at present, to discover what it is that makes one
part more than another naturally fit to be the seat of cancerous growth ;
or any part more fit at one time of life than at another. We are, of course,
disposed to look for explanation to peculiarities of tissue, and to their
ehanges with age ; and we can hardly doubt that these are chiefly influ-
ential : and yet, as the medullary cancers of the eyeball and orbit share
(p. 645), we must ascribe something to locality as well as to tissue. The
mBoeatum of cancers is certainly not wholly determined by aptness of
structures. An osteoid cancer, for example, affects at once cancellous
and compact osseous tissue, medulla, periosteum, and surrounding mus-
oles ; a medullary cancer may occupy, from the first, many tissues both
within and around the eyeball : when a cancerous breast is cut away, the
recnrrent growths appear very commonly in the scar, t. e. in the same
locality, though all the tissues affected by the primary growth are gone.
Very numerous cases such as these might be dted ; they cannot, I pre-
■ame, be explained, but they suggest the need of considering always
that morbid products may be determined to certain places as well as to
certain gtructures. As each natural organ has its appropriate place as
well as structure, so, but with almost infinitely less regularity, morbid
growth may have laws of allocation.
A question of much interest is connected with the liability of other
tumors to become cancerous ; it is of interest not only as a subject of
pathological inquiry, but in relation to an opinion which is often made a
reason for operations : namely, that if a tumor of any kind is left to its
own course, it is not unlikely to become cancerous. I have looked
carefully into this question, and I believe there are no facts sufiScient to
justify the opinion that an innocent tumor is more likely to become the
seat of cancer than any other parts of the body in which it is growing.
The only case supporting such an opinion is that of cystic disease of the
ovary. I think there is no doubt that it is not unfrequent for cysts of
the ovary to exist, for a time, as an innocent disease, and then become
the seat of cancerous growths. But, then, the case of cystic disease of
648 eiVIEAL PATHOLOeT OV OAVCim.
the ovary is so peculiar in all reepcN^ts, that we eannot deduce firoB itiny
rule to be applied to instances of other tumors.
With regard to the supposed transformation of any other tamoit all
cancers, the facts are very few.
M. Lebert states that he has twice met with tumors which were at fnt
of an innocent kind| but afterwards became cancerous ; but he does not
state whether they were in persons who had cancer in some other part:
i. e. whether the cancer in the tumor were secondary or primary*
Sir Benjamin Brodie mentions a case in which he remored a tOMi;
the general mass of which appeared to be fatty substance, somewhit
more condensed than usual, but ^' here and there was another kind d
morbid growth, apparently belonging to the ckss of medullary or fangoil
disease."* A few other cases of the same kind are related ; and loat
would assume that in all the cases of mixed cartilaginous and cancarMi
tumors (mentioned at p. 444) the cartilaginous growth was bciig
transformed into, or superseded by, the cancerous one. I see m
good evidence for such an assumption : the contrary might very well be
maintained in argument ; or the two growths might be re^uded m
simultaneous in their origin.
It need not be denied that cancerous growths may occur in tawn
that were previously of an innocent kind, but I feel quite sure that tlMN
may be regarded as events of the greatest rarity. • My own ezpericaee
has (perhaps by chance) been such as would indicate that innocent toomt
are less liable to cancer than the structures they resemble ; for, as I ksie
elsewhere mentioned (p. 478), I have seen three cases in which caiieer
affected the natural structure of the mammary gland, while, dose by,
mammary glandular tumors remained unaffected.
It may be asked, whence is derived the impression that so commoiily
exists, that a tumor of an innocent kind is peculiarly apt to becoae
cancerous ? I believe it has arisen from several different kinds of decep-
tive cases.
First, there are the cases of what I have referred to as the suspensioa,
for a time, of cancerous progress ; in these the cancer seems for a ivm
to be an innocent tumor ; it is judged to be so because it remains so long
quiet ; and when it assumes the ordinary progress of cancer, it is said to
be a tumor once innocent, but now become cancerous. This might have
happened in the first and fourth of the cases mentioned at p. 554 : yel,
without doubt, in these cases, the tumors that made little or no progretf
had all along the cancerous structure.
Another class of deceptive cases have a history of this kind : — a tamor
is removed which is apparently of an innocent sort: but, some time after,
a cancer appears at the same part. The explanation of some of these
cases is (as I suggested in p. 478), that a simple tumor has grown in a
person having an hereditary or other constitutional tendency to cancer;
* LeotnrM oo Patbolofj and Sargerjr, p. 3S2.
CANCBR0U8 AFFECTION OF BIXPLB TUM0B8. 649
and that, in the removal of this tumor, the surgeon has unwittingly sup*
plied, by the local injury, what was needed for the production of a can-
cerous growth ; he has made some locality apt for the manifestation of a
constitutional disease already existing.
In a third class of cases, we may find in the same person a succession
ni tumors, of which the first may have few or no characters of cancer,
and the last, as if by gradual change, may be evidently cancerous. I
have referred to this in connexion with the recurring fibroid tumors
(p. 418) ; but the facts have little bearing on the question whether an
innocent tumor can become cancerous: for here the transition is effected,
not in one tumor, but in a succession of tumors.
By cases such as these we may, I believe, explain away the grounds
tear the assumption that simple or innocent tumors are parts peculiarly
qpt to become cancerous. Cancers may grow in such tumors, but the
event is so rare, that it cannot, in any given case, be reasonably antici-
pated.
It remains to consider how parts may acquire an aptness for cancerous
growth in them, or, in most instances, how that aptness which they
naturally possess may be increased : for it is very observable that the
^exciting causes" of cancer act with far greatest effect on the parts which
are, without their help, most liable to it.
Three chief conditions may be here enumerated : namely, the results
of certain diseases in intrauterine life, indicated by congenital defect ;
the results of certain diseases after birth ; the consequences of injury.
The aptness for cancer due to congenital defect is exemplified in the
peculiar liability of moles or pigmentary n»vi to become the primary
seats of melanosis. I have already enlarged on this (p. 610), and have
fioggested that these defects, which we can easily see, may be only exam-
ples of a larger group, which, though invisible, are not less efficient in
rraidering certain parts peculiarly liable to cancer.
The aptness due to diseases after birth may be illustrated by the lia-
bility of the incrusted warts and scars, and other morbidly changed parts,
to become the primary seats of epithelial cancers. For other than epi-
thelial cancers the effect of disease in disposing parts to cancer is slight.
We find no remarkable liability in parts that have been changed by
inflammation, whether of common or specific kind. Few theories, I think,
have been less founded than those which have regarded scirrhous or me-
dullary cancer as, in any sense, the result or sequence of inflammation*
Parts that have been the seats of inflammation may become the seats of
cancer ; but I doubt whether the proportion in which they do so be much
greater than that in which they become cancerous when apparently
healthy.
The influence of injuries is more evident. About a fifth of those who
have cancer ascribe it to injury ; and although, doubtless, some of these
are wrong in their belief, yet, among the rest, there are some in whom
650 OBKBRAL PATHOLOOT OF OAirOlB.
the consequence of injury is too evident to admit of doubt. But Wrf %
distinction must be made as to the manner in which injury promotes tbt
production of cancers.
In certain cases, the cancerous growth appears immediately aftfr the
common effects of the injury. A person receivea (suppose) a blov. ind
when its direct effects are passing away, a cancer appears in the injared
part. I have cited cases of this kind in the history of medullary caDten
(p. 552) ; among which, indeed, the event seems more frequent tliu
among those of other forms.
In other and more usual cases, a much longer interval passes betwen
the injury and the appearance of the cancer. The injured part teems to
recover, without change of structure. In most cases, indeed, sneh u
those of ordinary blows on the breast, the direct effects of the injury an
not such as we might expect to be followed by structural change ; j^
doubtless, the part remains different from what it was.
In a third class of cases, which are most frequently exemplified in tkt
epithelial cancers, the injuries appear to be ineffective unleas thev ir»
repeated time after time, so as to produce, we may suppose, a real change
of structure in the part that at length becomes the seat of cancer (p. 5M^
It is important to remember these different relations between mjnm
and the growth of cancers, not only for pathology *s sake, but for practiee.
It is often stated, as a rule, that those cancers are least likely to retm
(it should be said, to return quickly), after removal, which have foUovcd
the receipt of injury, or some previous disease in the part. Now, this is
only partially true ; it is, probably, often true of the epithelial cancfis
that have grown in the seats of repeated injury, of frequent ulceration,
and the like ; but I know no facts relating to scirrhous and medoilaiT
cancers that will support it ; and I believe that the cases in whidi can-
cers follow quickly after accidental injury are just those in which a speedy
return may be anticipated after operations. The growth of a cancer
immediately after an injury implies the existence of an intense cancenwi
diathesis, which no removal of the cancer is likely to affect ; but when i
part has been repeatedly injured, and only at length becomes the seat of
cancer, it implies such a low degree or stage of cancerous diathesiii ai
we may expect to remain long '^ latent," if the slowly-prepared localitv,
with all that has grown in it, be cleanly removed. Of the intemediatt
cases, in which some clear time intervenes between the injury and the
growth of the cancer, we must hold, I think, that the abiding effects of
the injury keep the part in a state peculiarly apt for the growth, till the
constitutional condition is established. This being complete, the removal
of the growth cannot change it ; and the injury done by the operation
would be enough to prepare a place, if none elsewhere were appropriate,
for a recurrent cancer.
QUB8TI0K OF CANCEROUS TRAK8F0RMATI0N. 651
LECTURE XXXIV.
GENERAL PATHOLOGY OF CANCER.
PART n.
STRUCTURE AND LIFE OF CANCEROUS GROWTHS.
I ENDEAVORED to illustrate, in the last lecture, those two conditions
which, judging from the general history of cancers, and the analogy of
other specific diseases, we must assume as necessary precedents of a can-
cerous growth : namely, the cancerous diathesis, constitution, or morhid
condition of the blood, and the condition of some part appropriate for the
growth. Now, according to the same analogy, the assumed cancer-ma-
terial in the blood, if it cannot be removed by any natural excretory
organ, will determine the f(Trmation of some abnormal organism in
wluch itself may be incorporated ; and this organism will have a specific
structure and mode of life significant of its origin. It is of these — the
general structure, composition, and life of cancerous growths — that I
shall now speak.
It maybe generally held that the characteristic structures of a cancer
ire altogether of new formation. But questions are often raised whether
natural structures may not be transformed into cancerous ; or, whether
oanoerous materials may not be simply transferred from the blood into
the natural textures ; or, whether natural structures can assume can-
cerous properties. I believe such questions may be thus answered : —
(1.) It is not probable that any structure, once completely formed, can
be transformed into any other. Structures may change by degeneration ;
bat in this their changes are as limited and as normal as in development.
The instances in which natural or other structures are supposed to be-
come cancerous are, chiefly, those in which new-formed cancer-structures
are inserted or infiltrated among, or, sometimes, within, those of the
affected part. Of such cases we may say that the part becomes the seat
of cancer ; not that it becomes cancerous.
(2.) It is possible that, in the mutation of structures effected in the
nutrition of certain parts, the elemental structures successively formed
may gradually assume the appearance and properties of those of cancer.
It has often been observed, in cases of cancer of the liver, that every
gradation of structure appears, from the natural to the cancerous ; and
that, among the microscopic structures, are many of which it is hard to
say whether they be hepatic cells or cancer-cells. It may be that this
only exemplifies the tendency of cancer-structures to be conformed, in
652 aiNEBAL PATHOLOGY OF OAKCBK.
some measure, to those of the adjacent natural parts ; but it may also be,
that both the fact and this well-known tendency are evidences that can-
cerous properties may be gradually imparted to the undeveloped blas-
tema in a part, so that the elementary structures successively formed from
it may gradually assume more of the characters of cancer. In other
words, as in inflammations we observe the wider deviations from the nor-
mal methods of nutrition or secretion, the larger the proportions are m
which the inflammatory exudation is mingled with the normal products
of the part (page 223) ; so, it may be, increasing quantities of cance^
ous material, added to natural blastema, may be represented by succes-
sive gradations of structure. I cannot doubt that transformation into
cancer is, in this sense, possible ; but its occurrence is not to be assumed
as frequent, and is, probably, limited to such organs as the liver, whose
elementary structures are of the same general type as those of cancer,
and are, in the ordinary process of secretion or nutrition, quickly changed
(3.) It is possible that undeveloped cancer-material may be separated
from the blood, with the materials of natural excretory organs, and may
be for a time incorporated with the transient structures of such organs.
We may assume this from the analogy of the cases in which we beliere
that other specific morbid materials are thus eliminated from the blood,
as weU as of the cases in which certain materials, which should be sepa-
rated from the blood by appropriate organs, are, when the oflSce of those
organs is hindered, vicariously eliminated by others. In both these cases
we believe that alien materials are, for a time, incorporated in the stmc-
tures of the eliminating glands, and then discharged ; and it is, in like
manner, possible that cancer-materials, though their ordinary tendency
is to determine the formation of peculiar structures for their incorporation,
may be incorporated in those of natural glands.
So far, then, as the gradual change accomplished in a succession of
structures, or the introduction of cancer-materials into the elemental
structures of excretory organs, can be called a transformation, the term
is not chargeable with the absurdity which some impute to it. And the
belief of the possible transference of cancer-material into some gland-
structure is worth holding, for it encourages one of the few hopes of
curing cancer that at present seem reasonable — the hope, namely, that
means may be found by which the morbid substance, transformed or
combined, may be constantly eliminated from the blood through the tran-
sient structures of some gland.
But these things are only possible : the unhappy rule is, that the natu-
ral consequence of the cancerous condition of the blood is, sooner or
later, the formation of a cancer with specific structures and mode of life.
Concerning these, it may suflice if I collect and comment upon the prin-
cipal facts detailed in the foregoing lectures.
In general construction, cancers may be either infiltrations or separate
masses: i. e. their elementary structures may be either commingled, and
OIVBEAL 00N8TBU0TI0K OV OAHOBB. 658
fonn one mass, with those of a certain portion of a natoral part, or
they may be collected unmixed in a mass round which the natural tis-
sues are extended. In any case, the mass they form is a growing part ;
and herein is the ground for classing them with tumors, and for sepa-
rating them from those results of disease, such as inflammatory pro-
ducts and tubercle, which may be increased, but probably not by their
own power of growth. (See p. 819, &c.)
In both their likeness and their unlikeness to other tumors, cancers
exemplify what is common among specific diseases, namely, that they
take certain general characters of common diseases, and, as it were,
stamp them with some specific mark. Syphilitic eruptions are known by
■ome specific character, added to those which are common to other erup-
tions of the same group : each specific form of ulcer has its 0¥m, toge-
ther with common, characters; so, cancers have many characters in
oommon with other tumors, but specific characters are superadded. (See
page 805.)
When, as in infiltrations, the cancer-structures are mingled with those
of a natural part, the most frequent event is, that the growth of the
cancer preponderates, and at length excludes that of the natural struc-
tures ; so that, finally, the latter disappear, and a substitution (to use
M« Lebert's term) of cancer, in the place of the natural tissues, is effected.
But the reverse of this sometimes happens ; instead of atrophy, hyper-
trophy ensues in the natural structures of the affected part ; and within
the same area both normal and abnormal structures grow excessively.
Thus it is with the growths of bone that form skeletons of the medullary
cancers, and with those of fibro-ceUular and elastic tissues that extend
into the exuberant epithelial cancers.
The cancerous substance may be found in a rudimental state, as an
undeveloped blastema. Vogel, whom Yirchow generally confirms,'*' de-
flcribes it as a firm, compact, amorphous substance, like coagulated fibrine,
which is rendered transparent by acetic acid, ammonia, and other caustic
alkalies, and sometimes includes molecular granules, which consist of
modified proteine or fat.
The developed cancer-structures, if we except the few cases in which
they are fibrous or osseous (pp. 510, 615), may be generally described
as formed of nucleated cells, or of such corpuscles as are rudimental of,
or degenerate from, the nucleated cell. Herein, and in the fact that
the corpuscles are neither imbedded in formed intercellular substance,
nor orderly arranged, lies one of the characters by which cancers are
distinguished from other tumors, and from all natural parts. Their
chief heterology, in respect of construction, is in this disorderly crowd-
ing of their elements; and I believe it is constant, unless when they
imitate the plan of some adjacent natural gland-structure (pp. 538, 547).
We observe, in the larg^ minority of cancers, two primary or founda-
* In hiB Aiohiv, B. i p. 111.
654 aXKBRAL PATHOLOGY OV CANOBB.
tion-forms of cells, of which the respective types may be found in gknd-
cells, and in epithelial or epidermal cells. Of the former, we hare
examples in the ordinary cells of scirrhous and medullary canows (pp.
496, 539); of the latter, in the ordinary epithelial cancer-cells (p. 578);
and it is, perhaps, very significant of the meaning of cancer, that the
forms which its structures are most prone to assume are after the patten
of those belonging to the natural structures, whose office is to Bepuitt
whatever is refuse or abnormal from the blood.
I say, the cancer-cells are formed on the types of excretory f^kuA
cells and epidermal-cells ; yet, without deviating from the general ^pe^
they have special characters by which it is seldom difficult to distingnkk
them. The question is often asked. What are the characters of the tne
cancer-cell? or. Has the microscope discovered any structure which ii
decisive of cancer, wherever it is found? The answers may be,— {1.)
Where cells, such as are described at pp. 496 and 578, are found alooe^
or chiefly composing a tumor, we may be certain that the tumor is i
cancer : we may, therefore, regard these as especially cancer-cells. (2.)
When a tumor is composed, chiefly or alone, of corpuscles, such as the
nuclei described at p. 538, or any others which we can trace as rudimenti
or degenerations of the cancer-cells, the diagnosis of cancer is not leas
certain : structures such as these are found composing none but cancerooB
tumors. But if the question be changed to, — Are there any canoen
which are not formed of structures such as these? — ^the answer must be
affirmative : for there are rare tumors which present the whole clinical
history of cancers, and which should therefore be called by the same
name, though they have not these peculiar cancer-structures, or have
them in very subordinate quantity. I do not refer here to cancers of
which all the structures are imperfect, or degenerate, or diseased ; but to
such as the fibrous cancers (p. 510), the osteoid (p. 615), and certam
varieties of the medullary (p. 638 to 540).* These all deviate from
the assumed specific cancer-structures ; and two of these, the fibrous and
osteoid, approximate to the characters of natural tissues.
Together with the disorderly construction, and the peculiar cell-forms,
we may often observe, as characteristic of cancers, the multiformity of
the structures composing their mass. It is not equalled, I think, by any
tumors, unless they be the cartilaginous or the mixed glandular and carti-
laginous (pp. 423, 440). The variety of forms appears due, in part, to
the mingling of the perfect structures with such as are in variouB
stages of development and degeneration ; and, in part, to what seems
like a disorderly overgrowth and endogenous increase in cells and ihtir
* Some pathologists would exclude from the name of cancer all these tamers, and all
which are not composed of the " specific*' cancer-structures ; but I feel sure that we shall
do right if (when a choice must be made) we choose modes of life, rather than struc-
tures, for determining the affinities of morbid products, and for arranging them under gene-
ric names. As of all tumors, so, especially, of cancers, the true nature is to be appre-
hended only by studying them as living things. (Compare p. 320.)
OAKOBB-BTBUOTUBBS, OANCEB-OELLg, ETC. 655
eontents. All these forms have been already described; but they may
be thus enumerated and arranged : — (1.) The chief of those to be referred
to incomplete development are the free nuclei, and abundant undeveloped
liquid or other blastema (pp. 497, 587, 579). (2.) The chief forms due
to the degeneration are the transitions from cancer-cells or nuclei to
grftnule-masses (pp. 498, 578) ; the withering corpuscles with fatty dege-
nermtion found in the material like tubercle in cancers (pp. 498-99, 556) ;
the calcareous deposits (p. 557); the abundant granular matter; and the
occasionally mingled melanoid cells (p. 607). (3.) Overgrown or abnor-
mally developed corpuscles are seen in the various extensions of cell-walls
into angles and processes (pp. 497, 540, 578); and in the eulargement
of free nuclei and their assumption of the characters of nucleated cells
(pp. 497, 588, 579). (4.) The endogenous increase in cells is exemplified
in all that is described of the brood-cells and laminated corpuscles of the
epithelial and colloid cancers (pp. 579, 628).
It would be too tedious even to enumerate more forms than these of
the component cancer-structures, and I need not again describe them. It
10 not their multiformity, so much as the existence of many of them in a
•ingle mass, that is generally characteristic of cancer.
Various as are these corpuscles of cancers, it is yet to be observed,
that there is none so entirely different from those of normal structures,
that we cannot point out among them its type or paralleL No observa-
tion since Miiller's time has invalidated his demonstration of this prin-
ciple. The experienced microscopist will, indeed, very rarely fail in the
diagnosis of a cancer by its minute structures ; but he only discriminates
them as specific modifications of the nucleus, nucleated cell, endogenous
cells and other forms, of which the types are in natural parts ; he finds
among them no new type-forms.'*'
In like manner, the elemental cancer-structures show no method of
growth or development which is without parallel in natural structures ;
they are formed and increased according to the same general laws as are
observed in the normal rudimental structures; their peculiarities, in this
ngard, are chiefly in the seeming dborder that often prevails among
them, — ^in the absence of an apparent singleness of design.
The abundance of cell-structures in cancers has suggested that they
are lowly organized, and many consequences have been hence deduced.
The terms "high" and "low*' in relation to structures, are derived from
Y^rj arbitrary estimates, and are too fallacious for any important deduo-
tion in pathology ; still it may be observed, that among morbid products,
cancers should stand high rather than low ; for their elemental forms are
on a level with those of natural excretory organs, and more developed
than any but the best inflammatory lymph. If there were any corre-
* This is now sufficiently evident for all the simple cells and nuclei of cancer ; and the
more complex endogenous cells and developing nuclei find their parallels especially in cai-
tihige, the preparatory structure of medulla, and the thyroid and similar glands. (See, espe-
daUy, Rokitanaky ** Die Kropi;" and «* Ueber die Cyste ; ' and Virohow, in his Archiv, B. iii.)
656 GBNBRAL PATHOLOGY OF OAROBK.
spondence, such as has been assumed, between lowness of organiiation
and malignancy, the ordinary croupous or corpuscular lymph should be
a much worse material than cancer; but malignant properties, like ma-
lignant spirits, are not confined to the. vilest forms.
The proper structures of cancers are supported and held together bj
fibrous, membranous, or other connective tissue, forming their ^^ stroma."
This stroma, as I have elsewhere described, is formed, in the case of
cancerous infiltrations, by the natural fibrous or other tissues of the in-
filtrated part, which, in different cases, are either gradually reduced in
quantity or increased. In these cases the stroma is no proper cancer-
structure, and varies with the nature of the affected part (pp. 500, 53S,
572). But in distinct, isolable, cancerous tumors, a stroma is formed
appropriate to the cancer, and, in many cases, with a definite mode of
growth — the dendritic mode (pp. 542, 622). Generally, however, it is
only in its plan or construction that the stroma is peculiar ; its tissues
are simply membranous, or nucleated, or filamentous, or it may be
osseous: they are not cancerous."". We see, therefore, in cancers thus
formed, as well as in the cancerous infiltrations with overgrowth of the
natural structures, the coincident growth of morbid and of normal tissues
within the same area, and out of the same mixed materials.
With the stroma of cancers are their bloodvessels, among which we
must again distinguish, as in the preceding paragraph, that some are the
vessels of the affected part now involved in the cancerous infiltration,
others are new formed. Concerning the changes which the first-named
may undergo in the growth of the cancer, we have, I believe, at present
no knowledge. They are not, as in tuberculous infiltrations, gradually
destroyed or removed ; rather, they seem to be increased ; so that an
injected scirrhous cancer of the breast (for example) often appears more
vascular than the adjacent substance of the mammary gland, though, in
the first instance, it had only the bloodvessels of the part of the gland
which it occupies. No direct observations, however, have shown the
method of this increase.
The new-formed bloodvessels of the isolable cancers and the cancerous
outgrowths extend from those of the adjacent parts. It is by some
thought that they are formed as an isolated system of tubes in the can-
cer : I know no satisfactory evidence of this ; and the associated theory
of blood being formed in the substance of a cancer, and out of cancer-
materials, seems to me wholly untenable. The method in which the new
vessels extend into cancers has not yet been traced, but is probably not
• Exceptions to this statement must be made for certain fibrous and osteoid canrcrs, in
which the fibrous and osseous tissue, if regarded as a stroma for the mingled cancer-ccllj-
must be admitted as a proper cancer-structure; and for some cases of medullary cancer, in
which a kind of stroma is described as formed of series of elongated cancer-ceils.
It must be observed, also, that the line between infiltrations and isolable tumors is here,
as elsewhere, somewhat artificially drawn. It is not to be denied that the latter may involve
small portions of natural tissues, which may remain intersecting or partitioning their masses,
and supplying a ftamewoTV \i\yQt\ yrXvvc^i ^«\t "^eftuU&c stroma may be oonttnicted.
CANOBB-BTBUCTUBSS, CANOEB-CELLSy ETC. 657
different from that observed in olher new formations (pages 145, and
237). Neither has anything specific in their structure or method of
arrangement been yet observed. The descriptions already given of them
(pp. 533 and 623) will show that the bloodvessels of cancers do not
differ from those of other abnormal growths, except in that, generally,
their calibre is more than proportionate to the thickness or complexity
of atmcture of their walls. Hence the term ^' colossal capillaries ;" and
henoe, when the bloodvessels are abundant, the likeness to the simple
vaaoular erectile tumors : but in neither of these respects are the vessels
of cancer without parallel in those of natural parts ; those of the pla-
eenta and of the cavernous erectile tissue might be their types.
Such are the component structures of cancers. We might hope that
chemistry, carrying its analysis far beyond the reach of sight, would
find in them something as different from natural compositions, as their
mode of life is from that of any natural member of the body. But it
has failed to do this ; and the numerous analyses made since those of
Miiller have not materially added to his results."" In a general compari-
son, the cancers are distinguished by the predominance or exclusive
existence of albuminous compounds, while in the non-cancerous tumors
gelatinous compounds (or in the adipose tumors, the fatty) are the chief
constituents. But there are large exceptions on both sides. The fibrous
and osteoid cancers yield abundant gelatine ; the albuminous sarcomata
of Miiller (including probably, many of the least developed proliferous
cystic tumors, and the recurring fibroid tumors) are as albuminous as the
typical cancers. It is probable, moreover, that the broad general dif-
ference between albuminous and gelatinous growths is not directly related
to their respective properties, as malignant and innocent, but to their
retaining or passing beyond the cell-form.
The want of a more definite result from chemical analysis is not to be
ascribed to the absence of difference between cancerous and normal
materials, — ^we may be nearly sure that they are chemically essentially
distinct, — ^but, rather, to the fact, that an exact analysis of cancer-struc-
tures is nearly impossible. That which would be given to a chemist for
examination is not a pure cancer-material, but a mixture of it with the
materials of blood, bloodvessels, connective tissue, and, in many cases,
of the natural or degenerate structures of the part in which the cancer
has been growing. Add to this, that, in every sample, the cancer-struc-
tures themselves are probably in all stages of development and degene-
ration ; and the search for the essential chemical properties of cancer
will surely seem as difficult as it would be to find those of muscle, or of
bone, in the analysis of the whole of a foetal, or of a paralytic, limb.f
- * The best of these analyses may be found in Lebert's Traits Pratique, p. 44, e. 8.
t The case of the colloid material may seem not open to this objection ; but the colloid ii^
probably, Dot a true cancei^eubstance, but the product of disease in cancer.
42
658 eiKBBAL PATHOLOOT Of CAlTOim.
In BtadyiDg the life of a canceroiis growth, we have alwsjs to
it as adding to the conditions of disease which already existed, and vWk
usually still continue ; it is a new factor in an already complex wirbii
process. The formation of cancerous material in the blood does not cc«e
because some is incorporated in a growth ; the transformations of ptrta»
making them apt for the allocation of cancer, do not cease became oae
part is occupied. In all the history of cancers, therefore, we hafc ts
study the continuation of those processes which I described, in the la«
lecture, as preceding the growth of the cancer, and which now (witk
rare exceptions) are concurrent with it, and increase with it
Before the formation of a cancerous growth, we trace two distiMt
though usually concurrent, processes : namely, that which leads to tlie
cancerous condition of the blood, and that which makes certmin parts fit
to be seats of cancerous growths. When once a growth is formed, it
introduces a third element of disease, without necessarily remoTing or
diminishing either of those that preceded it. As a living part, the cancer,
like any other tumor, has the power of self-maintenance and of growtlu
which power, though favored by the continued or increasing canceroai
condition of the blood, is, probably, not dependent thereon. Abo, ii
the results of its nutrition, the cancer reacts upon the blood, and throagk
it influences the whole economy : and these influences are added to the
cancerous diathesis or cachexia which is usually, at the same time sai
of itself, increasing.
The manifestations of life in a cancer may be divided (bat it is too
artificial a division to be followed far) into those which are progressire,
and those which are retrogressive. The latter are traced in the ranoos
degenerations and diseases of its structures ; the former in its growth,
extension, and multiplication.
The chief characteristics of the growth of cancers are seen, in thcxif
that are infiltrated, in their invasion of all tissues, as if indifferently.
Thus the scirrhous cancer of the breast, though limited for a time to
the mammary gland, at length extends beyond it, and gradually occupies
every surrounding part alike : thus the epithelial cancer extends from
the integument of the lip to its muscles, glands and all deeper tissues,
and thence to the gum and jaw ; and thus the medullary cancer grows
into and through the walls of bloodvessels and other canals, and extendi,
among their contents, along their cavities. Such reckless growth (if it
may be so called) is scarcely known except in cancers. They supplj,
abo, the instances of most rapid increase ; but although they do this fre-
quently enough to make rapid growth one of the diagnostic signs of can-
cers, yet the cases are far from rare in which the growth is very slow.
Few diseases are more variable than cancers are in this respect. (Com-
pare p. 502, 553, 598, 427.)
It has been assumed that the appearances of endogenous increase in
certain cancer-cells are indicative of a peculiar inherent capacity of growth.
But this is far from certam and is made improbable by the fact that the
LIVE OV CANCEB9: GBOWTH. 659
endogenous productions are most abundant in epithelial cancers, whose
arerage rate of increase is least ; and that those medullary cancers which
have only free nuclei, or imperfect nucleated cells, are among those of
most rapid growth. The rule is more nearly true, which these instances
exemplify, that the rapidity of growth among cancers is inversely pro-
portionate to the development of their elemental textures. But this finds
.exceptions in the very quickly increasing and multiplying fibrous and
OJBteoid cancers.
Two things administer to the growth of a cancer ; namely, (1) the con-
tinued formation of the specific material in the blood ; and (2) the inherent
power in the cancer, as a living part, to assimilate to itself the common^or
indifierent materials of the blood. The first of these maintains and aug-
ments, as it originated, the growth; the second efiects an independent
increase, like that of a non-cancerous tumor. The efiect of the first is
shown in the fact, that the rate of increase in cancers is, usually, propor-
tionate to the indications of constitutional affection; the effect of the
second is shown in the increase being accelerated by whatever aug-
ments the supply of blood to the seat of cancer (p. 516) and (if the facts
be as I have stated them at p. 543, in the growth of cancers after inocu-
lation.
In ordinary cases, both these conditions are engaged in the growth of
cancer ; but if the first fail, the second may suffice. The cancerous
diathesis may cease, or be exhausted for a time, or sometimes even per-
manently ; cancer material we may suppose, is no longer formed in the
blood ; yet the cancer may subsist and increase by its own power. It
does so like any other tumor ; especially like those which I mentioned (p. 829)
as beginning during or after some general disease, but continuing to grow
when that disease has ceased.
Now, in this state, the cancer is essentially a local disease, living upon
the materials of blood restored to health, though capable, probably, of
infecting that blood, and inducing secondary phenomena of extension
and multiplication. It illustrates, in this state, a principle which we are
too apt to forget : namely, that diseases of constitutional origin may be-i
come wholly local. The origin of local diseases in constitutional condi-
tions has been well studied, and the necessity of constitutional treatment,
in chronic as well as in acute diseases, has been rightly referred to the
local affections being maintained by the continued morbid condition of
the blood ; but it has been less considered that, after the constitutional
disease has ceased, the local one may, of itself, continue, and need local
treatment. Such cases are very frequent. ( One often sees syphilitic ulcers,
which, doubtless, had a constitutional origin, and were maintained by
specific material in the blood, and would have needed specific treatment
of the blood for their cure ; but now, while retaining their specific forms,
they are curable by local treatment alone. ' Just so it may be, though
very rarely, with cancers. While the cancerous diathesis is suspended,
660 QEHSBAL PATHOLOGY OV OAVOSE.
thej may subsist by their own powers of assimilation ; and I befien tbe
few credible cases of recovery after operation are to be referred to die
chances which have led to the occasional removal of such as were tim
localized.
The extension of cancers (so far as it may be distinguished from tkor
growth) is that which takes place through lymphatic vessels to tkor
glands. The number of cases in which lymphatics, filled with caii«r,
have been traced from the primary growth to the nearest glands, is sof-
cient to make it probable that the disease often thus extends contiDuouij
from the one to the other ; and that it is thus, as Mr. Simon exprcsNi
it, transferred by ^'continuity of blastema." But, even when such trMti
of cancer cannot be traced from the primary disease to that in the lj»
phatic glands, I think Mr. Simon's suggestion is very probably trat-^
that the disease is one of the lymph, not of the parenchyma or vessels of
the glands. We do not, indeed, yet know exactly the derivation of the
lymph, nor what is its relation to the materials of the part from whidi it
comes ; but what we do know of it is consistent with the belief, tkit
lymph, from a seat of specific disease, is likely to contain such of the
materials of the disease as may either be carried to the blood, or may be
organized in the lymph after the same plan as in their primary seat
The characters of the secondary cancers thus formed in lymphtric
glands are already described (pp. 508, 548, 588, &c.) ; and these genenl
principles may be gathered concerning them.
(1.) The disease in the lymphatic glands usually repeats exactly that
in the primary seat ; the apparent differences between them depend onlj
on the structures among which the cancerous elements arc placed Bot
this rule is not without exceptions (p. 505, &c, as cited above).
(2.) The cancer in the glands seldom appears before that in the pri-
mary seat has made considerable progress. At a general rough estimate,
it appears about midway in the course of the disease towards death. The
delay is, perhaps, not to be explained, seeing that lymph is carried from
the primary disease as well in its earlier as in its later stages.
(3.) While the disease in the glands makes progress, the primary di»-
ease usually keeps the lead which its earlier origin gives it. Occasion-
ally, however, that in the glands so far surpasses it that we are in danger
of overlooking the primary disease (page 504, &c.) I do not know how
the fact can be explained ; but it has its parallel in {he occurrence of
primary cancer in the glands that are usually secondarily diseased, and
in the recurrence of cancers after operations in the glands, rather than
in or near its primary seat.
(4.) The lymphatic glands usually become cancerous in direct succesnon
from the primary disease to the thoracic duct. The extension is, gene-
rally, made slowly ; in scirrhous and epithelial cancers the disease otitn
remains long limited to the glands nearest to its primary seat ; in neariy
all cases, also, it is prone to increase in these proximate glands
MULTIPLICATION OF CANCBBS. 661
more than in those more distant. Rarely, the secondary cancer appears
in distant, rather than in proximate, glands ; but in these cases it illus-
trates the multiplication, not the extension, of disease.
The multiplication or discontinuous increase of cancer may take place
in the following ways :
(1.) The cancer-growth may multiply itself, from its primary seat, to a
part not directly continuous, but in contact therewith. Thus Dr. Hodgkin
and Dr. Budd relate cases of cancer in abdominal and pelvic viscera, with
corresponding formations on the portion of parietal peritoneum, or other
parts in contact with them ; and thus there may be correspondence and
contact of cancers on the two layers of pleura, or on the glans and pre-
puce.
(2.) The multiplication may take place on a surface not in contact, but
continuous, with the primary seat ; as in cases by Mr. Simon (1. c), in
which cancerous growths were found scattered along the tract of mucous
membrane leading from primary cancers in the kidney and lung.
In both these cases, the multiplication of the cancers seems to be the
result of simple transference of the materials from the primary to the
secondary seat of growth : it is effected by a kind of inoculation. The
materials of a cancer, whether in formed germs or liquid blastema, pass
from its mass, and develope themselves, and grow, where they rest.
(8.) Cancers are multiplied in parts neither directly continuous, nor in
contact with the primary seat. In some instances the parts are near, in
others remote from, the primary disease.
When cancers are thus multiplied near their primary seat by " irradia-
tion," we find them, as it were, springing up in an area which gradually
widens, and of which the primary cancer is the centre. Thus it is with
the tubercles in the skin and muscles near a scirrhous breast (p. 505) ;
and with the* secondary medullary, osteoid, and melanoid growths scat-
tered round the main disease, but separated from it by intervals of healthy
tissue (pp. 611, 614).
I do not know that we can explain this mode of increase of cancers other-
wise than by reference to the seeming tendency of specific diseases to be
allocated, not only in certain tissues or organs, but in certain places or
regions (see p. 545). Certainly, peculiarities of tissue have little to do
with this grouping of the cancers around the primary formation ; for they
may be found, promiscuously, in all the surrounding tissues within a cer-
tain area. Neither does the course of lymphatic or other vessels seem
to determine their places.
In the increase of cancers by multiplications distant from the primary
growth, there is scarcely an organ that may not be affected. We see
this most easily in the cases of melanoid cancers ; yet their multiplicity
is probably not greater than that of other medullary cancers (see p. 611).
The cancers that thus least frequently multiply are the epithelial and
colloid, and those, of whatever kind, in the rectum, urinary organs.
662 QSHBBAL PATHOLOQT OF CAHOBB.
uterus, and brain. The organs in which the secondary cancers formed bj
multiplication are most frequently found are the lungs and liver ; the
latter, especially, in cases of cancer of the abdominal Tis<5era ; the for-
mer, especially, in those of the breast, limbs, and other parts whose blood
passes to the vense cavse. . After the lungs and liver, the most frequent
seats of such secondary cancers are, I believe, the pleura, bones, lym-
phatic glands, and subcutaneous tissue ; after these, no rule or proportion
can be stated, except that many of the organs in which primary cancen
are most frequent, are very rarely the seat of secondary cancer ; e. g.
the breast, uterus, testicle, and stomach."^
At present, probably, none but a very general explanation of this mul-
tiplication of cancers can be given : we can scarcely venture to gneM
what determines the above-mentioned peculiarities. The general explar
nation may refer the multiplication to two sources, which are independent^
though concurrent and mutually influential ; namely, the increasing can-
cerous diathesis or morbid condition of the blood, and the conveyance
and transplantation of cancerous matter by the circulating blood.
The constant increase of the morbid condition of the blood was shown,
in the last lecture, to be a general fact in the history of cancers. And,
although it may sometimes be represented only by the accelerating growtli
of the primary tumor, yet we might well expect that it would often pro-
duce a numerical increase of cancers. The common indication of the
most intensely constitutional cancerous disease is the simultaneous or
rapid formation of numerous primary growths in different parts. This is
sometimes witnessed at the very onset of the disease (pp. 548, 553) ; and
it is, probably, also exemplified in the later period of ordinary cases.
Certain cases scarcely admit of explanation, on the supposition that the
first-formed cancer is, in any sense, the source of all that grow after it ;
such, for example, as those in which a sudden rapid multiplication of can-
cers takes place (p. 554), and those in which they appear some long time
after the removal of the first-formed growth.
The second method of remote multiplication of cancers, that of convey-
ance by the blood, is sometimes visibly demonstrated, and may almost
always be assumed. I have spoken of cases (p. 637) in which cancers so
grow into veins, that we cannot doubt fragments may be washed from
them by the blood, and may grow wherever they come to rest : and I
related one instance of osteoid cancer in which this almost certainly oc-
curred (p. 619). But, even where no such intra-vascular growths appear,
similar events may occur. In a case of primary cancer of the liver, in
which the growths were all tinted with bright yellow by the bile, I found
numerous small cancerous masses of the same color infiltrated in the lungs ;
and the small branches of the pulmonary arteries leading to these were filled
with bright-yellow substance, as if they had been minutely injected with
chromate of lead. The accidental color of the cancer-materials, in this
* Lebert gives th« best statistics on ail these points (p. 81).
DEGENBRATI0K8 OF CAXCERS. 668
ease, made their transference from the liver to the Inngs very evident ;
but the same event is often, thoagh less plainly, traceable.
The transference of cancer-materials, with the blood, from a cancer
already formed, need not be always seen to be believed. Its frequent
occarrence is made very probable by the many points of correspondence,
which Dr. Walshe"^ has shown, between the dissemination of cancers,
and that of secondary abscesses after the entry of pus or other degenerate
inflammatory products into the veins. The peculiar liability of the livei'
and the lungs to be the seats of both these secondary diseases, and the
evidence that they are the organs in which foreign matters, introduced
into the circulation, are most commonly arrested, may nearly prove that
ihey> are, in all these cases alike, affected by materials brought to them
in the blood.
We need not assume that corpuscles of pus or cancer, or any kind of
germs already formed, ^must be thus carried for the multiplication or
dissemination of disease. A rudimental liquid, an unformed cancerous
blastema, mingled with the blood, may be as effectual as any germs ;
and must almost necessarily be assumed, in the explanation of cases in
which the dissemination takes place, not in the lungs or liver, but in
organs beyond them in the course of the circulation.
The materials conveyed with the blood from the primary cancer must
be such as are capable of development, in order to the multiplication of
the disease. In the ordinary absorptions occurring in the process of
natural nutrition, and probably, also, in those that take place in the
nutrition of cancers, the venous blood carries away only degenerate or
refuse materials, such as we may assume would be incapable of develop-
ment. I have mentioned cases (pp. 548, 558) in which masses of cancer,
probably thus degenerate, were absorbed, without any appearance of
consequent dissemination or other damage. We do not know what leads
to the removal of such cancerous matter as can be developed ; but the
necessity of some change in the ordinary process of absorption is evident,
and is the more worth studying, because there are corresponding similar
differences in the effects of the absorption of pus and other morbid pro-
ducts.
Such are the various means of numerical increase of cancers — ^by local
inoculation of parts continuous, or in contact with the primary disease ;
by extension, through a continuity of lymph, or of blastema, to the
lymphatic glands ; by transportation of potent cancer-materials with the
venous blood ; by the cancerous condition of the blood becoming, of
itself, more intense. In certain cases the increase may be accomplished
by all these means at once ; the secondary cancers, also, as soon as formed,
become like centres, from which a tertiary formation may be derived,
as they were themselves derived from the primary ; and to all this it
may be added, that, with lapse of time and failing general health, all
* Nature and Treatment of Cancer, p. 106.
664 OBNBBAL PATHOLOGY 09 OANOBR.
parts of the body are constantly becoming less resistant of disease, and
more appropriate for the residence of morbid growths.
I have now to trace a general history of the retrogressive life of cancers;
of that which, as I said (p. 658), is signified in their various degenerations
and diseases.
The degenerations of cancer-structures are like those of natural parts,
and of other products of disease. Examples may be cited of e?erj
form corresponding with those enumerated in pages (74 and 241).
(1) The withering, or wasting and drying, of the structures is exemplified
in many scirrhous and epithelial cancers (pp. 502, 578) ; (2) the fatty
degeneration is so common that it might be hard to find a cancer, in
some of whose corpuscles it does not exist. The granule-masses ('^ the
mulberry-cells'*) of cancers are hence derived, as they are from many
more morbid products. Hence, too, the ^^saponification" of cancers
(p. 557) ; while to the fatty degeneration, combined with more or less of
withering, we may ascribe the masses of substance, like tubercle, so often
imbedded in medullary cancers (p. 582), and the minuter spots and lines
of soft ochre or yellow substance traversing scirrhous and medullary
cancers, like a "reticulum" (pp. 499, 556). (3) A calcareous degene-
ration is observed in medullary cancers, and in osteoid (pp. 557, 613,
617); and, probably, exists in many instances mingled with the fatty
degeneration. (4) Pigmental degeneration is probably the essential
character of melanoid cancers (p. 610). (5) Thickening of primary
membrane is, perhaps, indicated in some of the cancer-cells whose walls
appear simply laminated (p. 580, fig. 103 d). A liquefactive degeneration
may occur in some of the softenings of cancers ; but, so far as I know,
it ensues only in connexion with disease. (Compare pages 105, 266.)
In the interpretation of degeneracy in cancers, we must again refer
to the two conditions of their life ; namely, the maintenance of the mor-
bid condition of the blood, and their inherent power of self-maintenance.
The supervention of another diathesis may lead to the degeneration or
death of a cancer (pp. 519, 558) ; but this is extremely rare. A trans-
formation of diathesis may, I am disposed to believe, lead to the degene-
ration of one cancer, while it promotes the growth of one or more others;
for there are cases of apparent metastasis of cancer, in which the primary
disease has withered, while secondary growths appear to have increased.*
But these cases, again, are too rare to be reasoned from ; and the usual
course of events indicates that degeneration of cancer is, in the great
majority of cases, an essentially local thing. For, commonly, part
of a cancer, or one mass in a group, degenerates, while growth con-
tinues in the rest ; and extensive degeneration is often found, in cases in
which the rapid progress of the disease has testified to the full maintenance
of the morbid blood. Hence the unhappy rarity of the recovery from
cancer. One that is degenerate or absorbed may be as ineffective for
DISSASX8 OF 0ANCBR8. 665
harm as one that has been cut away ; but the constitutional element and
progress of the disease are as little affected by the natural as by the
surgical process of removal.
We cannot tell what are the local events that lead to this degeneration ;
but I suspect that the chief of them is the local obstruction of bloodvessels
by growths of cancer into them.
The diseases of cancers, like the degenerations, are essentially local
processes ; they are most apt, indeed, to occur in the enfeebled general
health, but they do not certainly indicate a decreased diathesis. It may
suffice to refer, for examples of most of the diseases, to those already
cited (pp. 517, 557, &c.) ; but two require more consideration ; namely,
softening and ulceration.
Some have believed that softening is almost a natural event in cancers,
a change parallel with that in tuberculous deposits, and a necessary pre-
cedent of ulceration ; while others, recoiling from the error of this belief,
have written of the softening of cancers as a rare and unimportant acci-
dent. The truth is about midway between these extremes. There is no
probability that (as some have supposed) the hard scirrhous cancers ever
become medullary by any process of softening ; a softened cancer is very
different from a soft one. There is no natural tendency in cancers to
become soft in their later stages : those of the oldest date commonly
retain, if they do not increase, their original consistence. Neither is
softening a necessary precursor of the ulceration of cancers. But any
scirrhous or other cancer may be softened by degeneration, or, more
effectually and extensively, by inflammation of its substance. The fatty
degenerations of which I have just been speaking are usually attended
with a softening ; but the altered substance becomes drier and more
greasy than before ; it does not appear, in any degree, liquefied (p. 499).
That which is generally understood as softening of cancer is, so far as I
have seen, a more acute process, and the result of inflammation of its
substance. One may see it very well in the exposed protruding growths
of medullary cancers (p. 557) ; or in those parts of them which lie just
beneath inflamed portions of the integuments. Sometimes, also, within
scirrhous cancers that have rapidly enlarged, with heat and pain, and
redness of the superjacent skin, one finds large portions liquid, or else very
soft, as it were rotten, shreddy, and infiltrated with pale, yellow, serous,
or puriform fluid. Sometimes such softening has distinct appearance of
suppuration in the centre of the cancer ; but these cases (which have sug-
gested the terms cancerous suppuration or abscess) are, I think, most fre-
quent in the secondary epithelial and medullary cancerous affections of
lymphatic glands (pp. 559, 584).
If, as I believe, these softenings of cancer are the results of inflamma-
tion, they correspond with the softenings produced by the same disease
in natural parts (page 258) ; they are the results of such defective
nutrition as always' ensues in the proper textures of an inflamed part ;
a&d when pus is diffused in the softened canoer-aubatsxkiCA^ IhA ^t<^<i«aL
666 GXNBBAL PATHOLOGY OV CAKCIR.
may be compared with ordinary purulent infiltration, which is tlvtii
attended with loss of consistence in the affected part. With thb Tiew
the microscopic characters of the softened cancers agree.
Such softening as this, taking place within a cancer, generally leads to
ulceration, and to the discharge of liquefied and degenerate materiib,
with whatever of serum, or pus, or blood may hare been mingled with
them. This discharge is essentially similar to the opening of an abiem:
but it is less regular, and the ulceration is quickly more destmctiye, and
exposes widely the cancerous walls of the evacuated cavity.
I have already described both this and the other forms of ulceratioa
that may ensue in cancers (pp. 517, 555, 575). They are all, like the
degenerations, essentially local processes, and not indicative of any peci-
liar advance or transformation of the cancerous diathesis. UlceratioB u»
indeed, a feature of the later progress of cancer, and it is most likely te
occur in those whose health is most enfeebled ; it is, therefore, oftci
coincident with an exceeding intensity of constitutional disease ; but it ■
not the consequence of such intensity. The amount of oonstitutioul
disease is indicated by the growth, or by the multiplication, of canmf
rather than by anything which, like ulceration, implies imperfect naia*
tenance of their structures ; and so we commonly see one part of a cia>
cer growing rapidly, while another is being destroyed by uleeratioiL or
many growing while one is ulcerating. Now the growth is, generally,
the measure of the force of the constitutional disease ; the ulceratioB ii
the measure of the local defect of nutrition : and in these instances «e
may watch, at once, both the progressive and the retrogressive pheno-
mena of the life of the cancer.
While dwelling on the constitutional origin of cancerous growths I
must not forget their constitutional effects — the changes in the blood snd
other parts, which are their consequences.
I said that a cancer adds a new element of disease to those that vere
already in progress. And this may be said of it in consideration both of
its own life, and of the influence which its growth and changes have upon
the whole economy. If we assume a constant process of nutrition in
cancers, it cannot but be that the blood will be affected both by vhit
they take from it, and by what it derives from them in the process of
nutritive absorption. This latter source of change of the blood has been
too little considered, — the former, perhaps, too much ; for the quantity
of good nutrient material abstracted from the blood, in the growth of a
cancer, is probably very trivial, whereas what returns to the blood it
almost necessarily a morbid substance. It may be incapable of devriop-
mcnt into cancer, but, unless it can be at once eliminated, it must injuri*
ously affect the blood. What change it works we cannot tell ; nor can
we tell more of the later changes produced when complete cancerous ma-
terial is absorbed into the blood, or when secondary cancera multiply ia
important organs, hindering their functions ; or when ulceration ensoes
pain^ hemoTtha^, dSuM&ttx%%, ^ft^<^ %2uL ^ tLa variova aigns if
NOSOLOOT OF CAVCEB8. 66T
rained health. When these things are added to the still increasing can-
cerous condition of the blood, and when all, with mutaal influence, are in
progress, they make a state so complex that analysis seems impossible,
and 80 various that no single or general description can be true. The
general result is what is commonly called the cancerous cachexia ; but
(as I have said before) it should be called the secondary cachexia, to dis-
tinguish it from the primary, which may precede the formation of a can-
cerous growth, or, in its independent increase, may far exceed the pro-
bable consequences of the local disease (pp, 523, 560).
The constituents of the secondary cancerous cachexia, I say, are too
numerous and complicated for analysis ; still we must always recognise,
in the later stages of the disease, the double source of the morbid phe-
nomena ; namely, the progressive constitutional disease, and the effects,
direct or indirect, of the local disease. How nearly independent the
former is of the latter is proved by the results of removing the local
disease. The secondary cachexia and many of its components may be,
for a time, decreased ; pain and discharge, and all the local accidents of
the disease, may cease ; but the average lengthening of life is very trivial
(pp. 525, 561, 600). The fact proves, not only that the progress of the
peculiar constitutional part of the disease is nearly independent of the
local part, but, also, that the constitutional part generally contributes
most to the fatal issue. However, in this, as well as in the times and
manners of dying, and the times of recurrence after removal of the first
growths, the differences in the several forms of cancer are such as should
not be put out of sight by a general or summary description : death is
the common, and almost constant end of all, but its circumstances should
be studied separately in each.
In conclusion, let me add a few words respecting the nosological rela-
tions of the several forms of cancer to one another and to other diseases.
Here, as everywhere in pathology, it is difficult to keep the just mean
of classification ; to avoid, on the one side, confusion ; on the other, too
rigid circumscription. The many features of resemblance in all the forms
of cancer, and the large general history which may be truly written of
them, might lead us to merge all minor distinctions, and speak as of a
single and uniform disease ; but it would be easy to show that, if in this
view we write of the general symptoms, progress, and diagnosis of cancer,
or of the history of cancers in any single organ, we write vaguely, and
are obliged to omit many points of importance, for fear of contradictions.
If, on the other hand, we look at contrasts rather than likenesses, we
might be induced to separate some forms, as the epithelial and colloid,
firom the name of cancer, and to believe that the remaining forms have
no affinity with any other disease.
' I suspect that the errors of such extremes as these (in all nosology, as
well as in that of cancers) come from our attaching too much meaning to
the terms that imply specific distinctions among diaeaaea^ from ous
668 OENSBAL PATHOLOQT OF OANCBB.
proneness to think of them as if they meant the same as they do in
zoology. Now, there is no real correspondence between the two sets of
terms. A specific name, in zoology, usually implies that all to whom it
is given have origin from a common stock ; certain characters fixed, and
not changeable, beyond certain narrow limits, by variety of external cir-
cumstances; and circumscription, t. e. intervals of difierence between
them and other species, which intervals are not filled up by varieties or
intermediate forms. Now in all pathology, there are, probably, no such
species as these ; and the terms implying the existence of genera, spe-
cies, and varieties of disease, mean only that the products of diseases
may be arranged, and the diseases themselves considered, in larger and
smaller groups, according to the number and importance of the charac-
ters which they have in common. Such terms do not mean that the
borders of each group of diseases are naturally circumscribed ; they allow
that the borders of each are confused with those of every adjacent group.
With this meaning, I have adopted the terms used in the foregoing lec-
tures. The whole group of diseases included under the name (used like
a generic name) of Cancer or Carcinoma are sufficiently distinguished by
the concurrence in them of all the characters of malignant tumors enume-
rated in the twenty-first lecture (p. 324-329). But this group is not cir-
cumscribed; its borders are everywhere overlapped by those of diseases to
which other names are given : there are no one or two characters pathog-
nomonic of cancer, and found in it exclusively. The foregoing lectures
have repeatedly illustrated this, especially in the accounts of the recur-
ring proliferous cysts (p. 364), the malignant fibrous tumors (p. 409), the
recurring fibroid and fibro-nucleated (p. 412), certain cartilaginous tu-
mors (pp. 432, 443), some of the myeloid (p. 451) and mammary glandu-
lar (p. 474), and the rodent ulcers (p. 588). At the same time, this
want of definition in the assumed genus of Cancers has been exemplified,
it will be observed, chiefly by rare and exceptional cases ; all the general
facts collected in the lectures have illustrated the sufficiency of the con-
current signs of cancer for a ground of general classification (see p. 328).
Among the diflferent forms of cancer, I have already said (p. 605)
that there appear to be unequal degrees of difference, which may be
expressed by speaking of three forms — namely, the scirrhous, medullary,
and epithelial — as species, and of the remainder as varieties, of cancer.
All that has just been said of the want of circumscription for the so-
called genus will, I need hardly say, be applicable to these smaller groups.
But here is the chief point, at which, while avoiding too much precision,
we must also guard against indifference ; for, as it has been wisely said,
truth is more likely to emerge from error than from confusion. The
species and varieties of cancer, as of other diseases, do not correspond
with those of living creatures ; yet the differences of the groups thus
named are inconsistent with the theory of a single unchanging disease ;
and I believe the future study of the grounds of these differences will
prove very {rmtf\x\.\)ot\LmV\io^\^^^^XLV\si\\vi^^^
TT7BEBCLE. 669
As yet we can only speculate upon them in questions. Do they imply
80 many essentially and originally different morbid materials? or is there
one material for cancer, one carcinogen, which, like an organic radical,
may form different yet closely allied compounds, in its combinations with
the yarious substances provided by different bloods, or different parts ?
Is not this hypothesis more appropriate than the first for the less usual
phenomena of transformation, such as I have described as occurring in
the progress, succession, and hereditary transmission of the cancerous
constitution ? Is it inconsistent with the gradual fusion of the characters
of typical cancer in those of other diseases ?
LECTURE XXXV.
TUBERCLE.
One often speaks of cancerous and other tubercles, meaning only small
knots or knotted masses of the specified morbid growth ; and of tubercu-
lar cutaneous eruptions, meaning small circumscribed flattened elevations
or thickenings of the cutis. But when "tubercles," without any specific
designation, are spoken of, the word is always understood to refer to little
masses of a peculiar product of disease, the type of which is found in
the lungs as the essential anatomical constituent of pulmonary consump-
tion or phthisis. The same material as composes the pulmonary tubercles
18 found in many different forms and organs, and, wherever it occurs, is
described as "tubercle,*' or "tuberculous matter;'* and "tuberculous
disease," or "tuberculosis," is the usual designation of the specific dis-
eases, of which the essential feature is the production of this peculiar
matter.
Tubercle or tuberculous matter may be formed in distint^t isolable
masses, round which the adjacent tissues are extended. These, which
are most frequent in the brain, and, I believe, in the subcutaneous tissue,
may be like tumors, except in that they are not vascular, and, probably,
have no inherent capacity of increase. But the most frequent formations
of tuberculous matter are in infiltrations of the natural tissues, which in-
filtrations may be circumscribed, having definite, though generally irregu-
lar, outlines, or diffuse, i. e. wide-spread and indefinite.*
In the lungs (to which, on account of its exceeding frequency, we are
bound to look for its type) tuberculous matter appears, as Rokitansky
says, in two chief varieties, or in forms combining, or intermediate be-
tween them. These are generally distinguished as the "gray" and the
* Tbe name, tuberculous infiltration^ is commonly given to this difTuse form alone ; but in
die miliary and other tubercles, even in the lungs, the peculiar materials are equally infU-
tiBted among the natural tissues; only, in these the mfiUtaxioii Qcic\x\)\ft% «l d^&xift^ vt««^
670 TUBSRCLB8 19 THV LUK08:
^^ yellow*' tubercles ; or the gray tuberculous granulations, and the cni^
tubercles. It may also appear as a diffuse tuberculous infiltration, m\m
alone, or, more frequently, associated with the preceding forms, or tk
changes consequent on them.
The gray tubercles appear as masses about as large, on an average, u
millet-seeds (whence their name of miliary tubercles), imbedded in the
substance of the lungs. They are usually from a quarter of a line to a
line in diameter ; and when the lung is cut through, so that its flaitie
tissue can recoil and subside, they appear slightly raised on its cut fo>
face, and the finger may feel them as little firm resisting bodies set in tk
lung. They look round or oval ; but their borders are very irre gnlar,
with short outrunning processes. They are gray, semi-transparent, laj
moderately bright ; or, sometimes are very glistening, with a greenisk-
gray " cat's-eye" tint. In the latter case, they may look like little veaclei:
but they are always solid. They may be discrete, i. e. placed singly. laj
with distinct, though small, intervals in the lung, or collected in groops.
They occupy and involve in their substance the tissues of the lung. aaJ
are so connected, that portions of these tissues always adhere to tbea
when we try to separate them. They may be easily broken or cruM
and, when thus treated, they yield but little fluid.
The yellow tubercles in the lungs have the same general forms and n»
lations as the preceding, but are commonly larger and less firm, and are
more often grouped so closely that, by fusion, they make up nearly mi-
form tubercular masses half an inch or more in diameter. Thev are usoalh
pale yellow, or, yellowish-white, opaque, friable, dry, cheesy, smetrinr
the surface on which they are crushed. Very often, their color is varieJ
with a smoky gray tint, partly due to intrinsic change, and partly d^
rived from the pigment of the lung involved by them.
It has been generally considered that the two varieties of pulmoDirj
tubercle here described represent two stages of the same disea^ : thi
gray substance being, after a time, changed into yellow. Kokitan^kj.
however, holds that they are always different substances ; and that. thonjL
they may be found, side by side, in the same lung, or may be minirtn:
even in the same tubercle, yet the transformation of the gray into ih
yellow substance never takes place. His names of " simple fihrinoa*
applied to the gray tubercle, and "croupo-fibrinous'* to the yellow, may
imply that both the differences and the affinities between the two form.*
are comparable with those between the two chief varieties of inflamma-
tory lymph (p. 217, &c.).
The minute structures of both the forms of tubercle are essentialij
similar ; and their distinctive characters (in the state in which they appear
to persist longest) arc, the absence of bloodvessels (except of such ae are
involved in the deposit and not yet wasted), and the defectively deve-
loped or aborted state of the blastema and the corpuscles.
The blastema, or basis-substance of a tubercle appears, imally, ia
<-^^-
THIIB OHIBT rOBKB. 671
fragments or flakes of a moderately firm, clear, or dimly molecular snb-
Btance, BvelliDg luid made clearer by acetic acid. It is most abundant
in the gray tubercle, most molecular or dotted in the yellow. It baa no
filameDtODS appearance, no trace of developing nuclei or fibres.
Tbe corpuscles beld together by this substance are (a) abundant mi-
nutest molecules, granules, and oil particles of various but usually smalt
OK ; all these being extremely predominant in the yellow tubercle ; (i)
nuclei or oytoblasts, of various shapes and apparent structure, but all de-
generate or defective ; some glittering, hard-edged, wrinkled and withered ;
others granular, few or none with distinct nucleoli ; {e) nucleated cells,
rimilarly misshapen, withered, or granular ; (d) certain compound cells
desGribed on the next page.
Mingled with these, and varying according to the situation and cir-
cumstances of the tubercles, numerous other, but accidental, substances
are often found ; namely, (a) tbe involving and disintegrating struc-
tores of the lung ; membrane or elastic fibres, degenerate epithelial cells
of the idr-vesicles or minute bronchi ; (d) various and usually degenerate
products of inflammation from the adjacent parts, granule-cells and
^nssses, pus-cells, kc. : (c) molecules of calcareous matter, or of pigment,
and crystals, especially of cbolestearine.
Such are the ordinary constituents of pulmonary tubercle, and tbe
ihrivelled nuclei and imperfect cells, being usually the most abundant
and distinct, are called tubercle-corpuscles. Similar materials are found
composing the tuberculous matter in other parte. In the lungs, according
to Virchow* and Schroeder van der Kolk,t their origin may, in an earlier
stage, be traced in changes of the epithelial cells of the air vesicles.
tig. iu.t
The adjacent copies of tbe drawings by Schroeder van der Kolk may,
with his.description of them, suffice to explain the process.
* WOnlmrg Terbuidlungen, i. 81.
t Om dea Qxsprong CD de Vbrming ran Tub«rcula PulmoDDm: Nederlandsch lancet,
1S93.
X Fig. 115. Teiy ihin Mciian of ■ ponioa ortubercDlous lung, deiciibed in the text Hag-
nifiad 430 timea.
% ^ \ ** -^^
672 TUBEBOLIS IN THB LUNQS:
" The margin of an air-vesicle, from which most of the tubercle-cells ire
removed, is shown at a a a ; that of another adjacent vesicle, nearly filled
with tubercle-cells, at ( ( ( ; and that of a portion of a third vesicle, clear
of tubercle-cells, at c. At d the still unaflfected wall of the air-vesicle i»
shown covered with epithelial cells of various sizes and containing naclei,
oil-drops, and granular matter. In the middle and at the end of the
same vesicle are some cells of darker tint ; they are no longer flat, bat
filled with some material, and thereby more or less swollen and spherical;
they are epithelial cells more or less distended with fluid, and detached,
and, as the series of them shows, they constantly enlarge. In the next
vesicle, i, these cells have become much larger, and more closely adherent
It is observable that the largest cells commonly lie in the middle of the
cavity of the air-cell : the larger are mostly filled with many nuclei ; in
the smaller there is but one."
''It is thus evident, that these cells, which fill the air-vesicles and
make up the tubercles, are nothing else than epithelial cells, which swell
by imbibition of plastic matter, enlarge, and are detached from the wall of
of the air-vesicle. The cells which are placed in the middle of the vesicle
are, thus, the oldest, t. e. the first removed from the walls, the longest
exposed to the influence of the surrounding fluid, and
Pig.116.* therefore the largest, f They are all filled with gra-
^ ^'l^A |P§^ nular matter and minute oil-spherules, and in the
■J*|[«^9 ^^ larger, an increase of nuclei has taken place."
i0^i^^^ 4^^ '^If tubercles be examined in a somewhat further
3 ^ ^^3fe • advanced stage, when they show more tendency to
^^ softening, the larger cells just described are found
in much less quantity, and in place of them the air-
vesicle is filled with smaller cells [and nuclei]. Among these, however,
some smaller cells appear (as in fig. 116, a), containing smaller cells or
nuclei, which are completely like those that are free {bb) ; so that there
can be no doubt but that, in this state, the larger corpuscles are dissolved
or burst, and the smaller ones set free." These smaller cells and nuclei
set free are what have been generally described as the tubercle-corpus-
cles ; and, as I have already said, the tuberculous deposits, after the
earliest periods of their formation, may appear to contain no other formed
corpuscles besides them.
Now the most peculiar character of tuberculous matter which these
descriptions illustrate, is its early degeneration, its abortiveness ; it is
shown as a material which, after proceeding for a little way in the ac-
quirement of organic structure, then stops in its course, recedes, and
degenerates. This is evident, at once, in the shrivelled or granular state
* Fig. lie. Tubercle-corpuscles: magnified 420 times and described in the text G>pieH
from Schroeder van der Kolk.
t In tlie College Museum, No. 297, is the lung ofa Benturong (Arctictis Benturong), which
shows, apparently very well, this progressive accumulation of tuberculous matter from the
walls to the cenues ol \\\e «\x-ce\\%.
THEIB MINUTE STRUCTURE. 678
of the set-free nuclei and cells ; and the latter changes are still further
degenerative ; all prove tuberculous matter to be not only very lowly
developed but generally incapable of development.*
These latter changes may be again illustrated by the examples of
pulmonary tubercles, and, according to Rokitansky, may, like the diffe-
rences of the original deposits, be compared with the degenerations of the
fibrinous and corpuscular or croupous varieties of inflammatory lymph
(pp. 242, 245).
(a) The withering (obsolescence, or Verhornung of Rokitansky) is the
peculiar degeneration of the gray tubercle in the lungs. It loses, herein,
its lustre, becomes dry, dense, and hard, and shrivels into a shapeless,
or indistinctly fibrous, little mass. The change is sometimes associated
with a calcareous degeneration of the tubercles, and often with corre-
sponding changes in the part of the lung in which they are imbedded,
and which becomes dry, shrivelled, and dark with pigment.
(6) The calcification, or calcareous degeneration, occurs in the yellow,
and in the mixed, forms of tuberculous matter. When achieved, it may
be taken as an indication, like the withering of the gray form, that the
tubercles are not longer subject to change ; that they are, generally, ob-
solete, and without influence on the tissues around them. It may occur
both in recent yellow tubercles, and in such as are already softened ; it
is exactly comparable with the calcareous degeneration of inflammatory
lymph and pus, and is usually associated with withering and pigmental
degeneration of the surrounding substance of the lung.
(c) The softening or liquefaction of tuberculous matter is, also, observed
only in the yellow and mixed forms. Though more studied in tubercle
than in any other morbid product, it is not peculiar to it, but is probably
analogous with many other liquefactive degenerations, and may be in
all points compared with that of inflammatory lymph (p. 242). It con-
stitutes the so-called tuberculous suppuration, and precedes the forma-
tion of tuberculous ulcers and cavities.
The process of softening usually commences at or near the centre of
the tuberculous mass ; in the part of it which, we may believe, being
most remote from blood, is least able to maintain itself in even such low
development as it may have reached. The central softening is that
which is spontaneous and normal in a tubercle : it may be regarded as a
natural degeneration of the morbid substance ; but any collection of tuber-
* An exception to this statement must be made, for certain cases, in which one part of
what seems to be a uniform exudation is developed into, or towards, false membrane, and
another part passes through the degenerative changes of tubercle. Such an event may^be
seen, according to Rokitansky (p. 263), in the tuberculous disease of the peritoneum and
other serous membranes, and is due, he says, to a mixture of the tuberculous exudation,
and of that of ordinary inflammation. Schroeder van der Kolk represents (as in fig. 115. 6),
filaments of rudimental new-formed tissue, which, he says, are sometimes found among the
cells of pulmonary tubercle. In tuberculous peritonitis, the portion of material developed
into false membrane may become vascular, and may make a seeming, tbougli not a real,
exception to the rule of the non vascularity of tuberculous matter.
48
674 TUBERCLES IN THE LUNQS:*
culous matter may always be softened, at its periphery, by the mingling
of liquid products of inflammation in the adjacent tissues. The two pro-
cesses of softening may appear similar, and may coincide, but they are
essentially distinct : one is spontaneous, the other accidental ; in the one
the liquid material is the very substance of the tubercle, in the other it
is derived from without.
In the proper softening of a tubercle one sees its central part become,
first, soft, so that, when cut across, it looks cracked and crumbling,
and may be pressed away from the surrounding firmer part, leaving a
little central cavity. In further stage of the degeneration, it becomes
liquid, like thin pus, with flakes or grumous particles in a pale yellowish
turbid fluid ; and as the change makes progress, the whole tuberculous
mass may be reduced to the same liquid state.*
The liquefied tuberculous matter consists of the lowest of the corpus-
cular materials already enumerated (p. 671) ; but they float now in a
liquid containing more abundant molecules and particles of oily and cal-
careous matter. The usual sequence of the liquefaction is the discharge
of the liquid, by ulceration of the tissues enclosing it ; but if the liquid be
retained, it may undergo further changes, which may be compared with
those of the retained contents of chronic abscesses (page 254). The
chief are, that its fluid parts are gradually absorbed, and its fatty and
calcareous matters increase, till it becomes a dry, greasy, crumbling,
or gradually hardening, mortar-like concretion.
The discharge of a quantity of liquefied tuberculous matter, by ulce-
ration through an adjacent bronchus, or through the integuments of a
subcutaneous tuberculous lymphatic gland (for example), leaves a cavity,
vomica, or abscess ; when the discharge takes place from single small
tubercles, such as form beneath the surface of the mucous membrane of
the intestinal canal, an ulcer remains ; and these are, severally, suffi-
ciently peculiar in their characters to be known as the tuberculous cavity,
and tuberculous ulcer.
The ulceration efiecting the discharge is usually the consequence of
inflammation in the tisssues over the tuberculous matter, and resembles
that for the discharge of common pus. By similar inflammatory ulcera-
tion of its boundaries, the tuberculous cavity or ulcer may be enlarged;
but more generally, and more normally, its enlargement is due to the
formation and discharge of fresh tuberculous deposits adjacent to it.
This may be best seen in tuberculous ulcers of the intestines ; but the
same process occurs at the cavities in such parts as the lungs and lym-
phatic glands. At the borders and bases of the ca^^ty or ulcer one may
often find small secondary tubercles, which, following the same course as
the primary, liquefy, and are discharged into the cavity, or on the surface
of the ulcer, which they thus increase by adding their cavities to it.
Such changes may be seen- better, I think; in the tubercles in the spleen than in thcwe in
any other part: Mus.St, Bartholomew's, Ser. xxii. 2, 3.
SOFTENING AND OTHBB DBGENEKATIONS. 675
Other tubercles, again, may succeed to these and pass through the
same changes ; and when many cavities and ulcers are thus simultaneously
enlarging they come into collision, and two or more are fused into one of
sometimes vast dimensions.
In these changes, the tissue involved in the tuberculous deposits
(whether primary or later) soften, and are disintegrated and discharged
with them. There is thus, always a loss of substance in the affected
part, coextensive with the tuberculous cavity. But, the bordering
tissues, if not tuberculous, may be infiltrated with organizable inflamma-
tory lymph, which, in its development, may form a tough boundary to
the cavity or ulcer, and, if fresh tuberculous matter be not deposited in
it, may lead to complete healing.
9
Before illustrating the foregoing general account of tuberculous
matter, and of its principal changes, by some of the instances which are
chiefly interesting in surgical pathology, it may be well to speak of some
affections which have an apparent or real affinity with it.
Degenerative changes, similar to those which ensue in the lowly de-
veloped materials of tubercle, may produce a similar appearance in other
materials ; — especially, in those which consist of cells, or rudiments of
cells. Thus, it is common to find, in medullary cancers, and more rarely
in others, portions of yellow, half-dry, crumbling, and cheesy substance,
so like tubercle that, with the naked eye, they can hardly be distinguished
from it. The cancers in which they occur have been described as mix-
tures of cancerous and tuberculous matters ; but the microscope finds
that the tuberculoid, or, as M. Lebert calls it, the phymatoid, material
in them consists of cancer-corpuscles, withered, with fatty and calca-
reous degeneration, and mingled with molecular and granular matter.
By similar degeneration, material like tubercles may be found in carti-
laginous, rudimental fibro-cellular, and probably other, tumors. In all
these instances, the microscope may usually insure a just diagnosis, and
may prove that the tuberculous appearance is only due to a withering
and a fatty degeneration of materials that have nothing but their degene-
ration in common with true tuberculous matter.'*'
Greater difficulty of diagnosis exists when, through similar degenera-
tion, inflammatory lymph assumes the appearance of tuberculous matter.
It does so, sometimes, in chronic inflammation, or, when acute inflam-
mation has subsided, in lymphatic glands, in the testicle, and, I believe,
in some other parts. So, too, if the pus of chronic abscesses or other sup-
purations is not discharged, it may gradually dry ; and as its corpus-
cles wither, with fatty and calcareous degeneration, it may assume an ap-
* Virchow (WQrzburg Abhandl. B. i. ii. iii.) had proposed to speak of the change, in all
these cases, as a " tubercular metamorphosis," or " tuberculization," and was, of course,
misunderstood as if he had implied that every material may become tuberculous matter.
He suggests, now, that the change by which so many essentially different things may become
^ cheesy," should be called, ** the cheesy metamorphose."
676 TUBSBCULOID BUB8TAKCB8.
pearance very like that of tabercnlons matter. And, in all these caks,
the resemblance may extend equally to the microscopic character* ; »
that there are, I believe, no signs by which degenerate lymph or poi
may be, in all cases, distinguished from ordinary tuberculous matter.
When, as in the cases cited in Lecture XIV., p. 245, the lympli-ct-l«
have been developed and elongated before their degeneration, they hmj
be known from any corpuscles of tubercle; and the many nucktted
cells in tuberculous disease may be distinguished from the ordinary pro-
ducts of inflammation ; but neither of these forms mav exi^t, and then
I believe that a distinction of degenerate lymph from tubercle mav U
impossible. Certainly, it is often very difficult to say whethvr the
yellow, dry, and cheesy material, found in chronic enlargementji or pup-
purations of lymphatic glands, should be vegarded as tuberculous ro;ittrr,
or as withered and degenerate lymph or pus, proiluced by inflammati< n.
The same difficulty may exist in the similar affections of the ttntticlfs:
but in these, more than in the case of the lymphatic glands, we mav he
extremely doubtfid of any material being really tuberculous, if it l»e UwxA
in them alone, and not at the same time in other parts uf the genital
apparatus, or in the lungs. Similar difficulties may exist in the diagn «ii
between tubercle and some instances of chronic pneumonia.*
Thus, then, there are not a few cases in which materials like t)i<:v^> of
tubercles are found as results of diseases that are not tuberculous: r. r.
that are neither coincident with, nor according to the type of, tuhorcul«n«
disease in the lungs. And the difficulty hence arising is increa.4<Nl ^v
this; that both tuberculous products, and the varieties of degericratf
and withere<l lymph and pus, are especially frequent among por>'^»n* "f
the "scrofulous" or "strumous" constitution; so that the df«rt^ner.ue
lymph and pus are often described as "scrofulous matter:" and '* scro-
fula" and "tuberculous disease" are often regarded as the same disease.
It is, I fear, impossible to clear the confusion arising from tlie inter-
changing uses of these terms, or to define exactly the cases to which th»'T
should severally be applied ; but where definition of terms is impos^^^il'li*,
the next best thing is an understanding of their meaning aci^onlin;: to
general usage. "Scrofula" or "struma," then, is generally undorsttnid
as a state of constitution distinguished, in some measure, by poculianti<4
of appearance even during health, but much more by peculiar liability to
certain diseases, including pulmonary phthisis. The chief of these ** «ero>
fulous" diseases are various swellings of lymphatic glands arising fmoi
causes which would be inadequate to produce them in onlinary healthy
persons. The swellings are due, sometimes, to mere enlargement, as from
an increase of natural structure ; sometimes to chronic inflammation ;
• Virchow has wrinen fully on this point ; and a cleiir statement of hi* ami o'li-n*
opinion^ respecting the different forms of pulmonary phthisis, is giren by Dr. Jenner in tlie
Br. and For. Med. Chir. Review, Jan. 1863.
SCBOFULOUS AND TUBERCULOUS DISEASES. 677
sometimes to more acute inflammation, or abscess ; sometimes to tuber-
culous disease of the glands. But, besides these, it is usual to reckon as
"scrofulous** affections certain chronic inflammations of joints ; slowly
progressive " carious** ulcerations of bones ; chronic and frequent ulcers
of the cornea ; ophthalmia attended with extreme intolerance of light, but
with little if any of the ordinary consequences of inflammation; frequent
chronic abscesses ; pustular cutaneous eruptions frequently appearing upon
slight affection of the health, or local irritation ; habitual swelling and
catarrh of the mucous membrane of the nose ; habitual swelling of the
upper-lip.
Now these, and many more diseases of the like kinds, are, amongst us
both in medical and in general language, called scrofulous, or strumous ;
but, though many of them are often coincident, yet it is very difiScult to
say what all have in common, so as to justify their common appellation.
Certainly they are not all tuberculous diseases. Little more can be
said of them than that, as contrasted with other diseases of the same
forms and parts, the scrofulous diseases are usually distinguished by mild-
ness and tenacity of symptoms : they arise from apparently trivial local
causes, and produce, in proportion to their duration, slight effects : they
are frequent, but not active. The general state on which they depend
may be produced by defective food, with ill-ventilation, dampness, dark-
ness, and other depressing influences : and this general state of constitu-
tion, whether natural or artificially generated, is fairly expressed by such
terms as "delicacy of constitution,** "general debility,** "defective vital
power,** "irritability without strength.** Such terms, however, do not
explain the state that they express, for they all assume that there are, in
human bodies, different degrees of vital power, independent of differences
of material ; which is at least not proved.
Such is the vagueness of " scrofula,** and of the terms derived from it,
as commonly used in this country. They include some diseases which
are, and many which are not, distinguished by the production of tubercu-
lous matter. It has been proposed, but I doubt whether it be practicable,
to make "scrofulous** and "tuberculous** commensurate terms : as at pre-
sent generally employed, the former has a much larger import than the
latter. The relation between the two is, that the "scrofulous** constitu-
tion implies a peculiar liability to the tuberculous diseases ; and that they
often co-exist. Their differences are evident in that many instances of
scrofula (in the ordinary meaning of the word) exist with intense and
long-continued disease, but without tuberculous deposit ; that as many
instances of tuberculous disease may be found without any of the non-
tuberculous affections of scrofula; that, as Mr. Simon has proved, while
the diseases of "defective power** may be experimentally produced in
animals by insuflScient nutriment and other debilitating influences, the
tuberculous diseases are hardly artificially producible; that nearly all
other diseases may co-exist with the scrofulous, but some are nearly
incompatible with the tuberculous.
I
I
I
678 TUBBBCULOUB DISEASE
Now, whether we disuse, or still use in its vagueness, the term sorofnl^
we may make a group of the "tuberculous" diseases, defined hr ih<
peculiar morbid product, of which I have described the chief charact^^rs.
Only, at present, we must be content, I believe, to be sometimes in donU
whether the substance found in lymphatic glands, and commonly kTt«>Tn
as scrofulous matter, be truly tuberculous matter, or degenerate Ivrnpli
or pus.
The Lymphatic Glands, among the parts specially studied in suriricil
pathology, hold the first place in liability to tuberculous dis^eaK*. In
children, they are, even more often than the lungs, primarily affn'oit-l;
in adults, they are next to the lungs in the order of fre(iuency ; an<l in
all ages, whatever part becomes tuberculous, the lymphatic gland.^ id rt-
lation with it are apt to be similarly affected.
The glands most often primarily tuberculous are the bronchial, mesen-
teric, cervical, and lumbar. Their state, previous to the tubercular
formation may seem healthy ; or they may be pimply enlargeil ; or si;ni*
of inflammation may precede and accompany the deposit. RoLitaiifk?
says that, in some cases, the tuberculous matter, as in the gray pnlmonarj
tubercles, appears in small round masses of grayish substance. But iti
far more frequent appearance in the glands is, like the yellow, pulmonart
tuberculous matter, in the form of roundish or irregular deposits «»f yel-
lowish, opaque, half-dry, cheesy, crumbling substance. Such d*'p«-:a
are infiltrated among the proper textures of the glands. At fir^t 'li>-
Crete, and contrasting strongly, both in substance and in color, with ile
unaffected portions of the gland, they gradually increase, till tlit-y ii;at
completely displace the natural structure, with its bloodvessels, or 1« .-iw
only a thin outer layer of it, enclosing the yellow mass which tiny f«'rTii.
By the increase of the tuberculous matter, as well as by the swi-lli»^ -f
their proper textures, the glands are usually enlarged; they may aoijuire
even an enormous volume, and, when whole series of them are affm-irL
may construct great lobed and nodular swellings. In all cast-s, liowxtr,
the several glands maintain a kind of independence; so that oiio in it
enlarge while others diminish, and one or more may inflame or .•suppu-
rate, while, in others, the tuberculous matter remains stationary or reirv-
grades.
The minute structures in tubercle of the lymj^hatic glands arc <*«"irn-
tially similar to those described from examples in the lungs: an«i \ ir-
chow* has found that, in the first stage of the process, there is an ewk^
genous increase of nuclei within the elementary structures, similar t«» that
which I have described after Schroeder van der Kolk. The same softt-n-
ing and liquefaction, also, as in the lungs, is prone to ensue in tlu> lym-
phatic glands.
The softening is usually central, and thence extending may affect the
* WOrzburg Verhandlungen, i. 84.
OF LYMPHATIC GLANDS. 679
•
whole morbid substance. The result of the change is not a homogeneous
liquid ; but, rather, a mixture of thin, turbid, yellowish-white liquid, and
portions of soft, curd-like, cheesy substance, like fragments of tubercle
softened by imbibed fluid. To these are commonly added the liquid
products of the inflammation of whatever remains of the gland-substance,
or its capsule, and the surrounding parts. The mixture constitutes the
tuberculous, or, as it is generally called, scrofulous pus, of which the
chief characters, as distinguished from those of ordinary inflammatory
pus, are, that it has an abundant thin, yellowish, and slightly turbid
liquid, with white, curdy flakes, that quickly subside when it is left at rest.
The liquefaction of the tuberculous matter in the glands usually leads
to its discharge ; and this is effected, in the case of the cervical and other
similarly placed glands, by ulceration, which differs from that for the
opening of common abscesses, chiefly, in being slower, and attended with
less vivid and less concentrated inflammation. There is, therefore, less
disposition to point : the skin is, proportionally, more widely undermined,
more extensively thinned. Thus gradually, by thinning and inflamma-
tion, deprived of blood, the inflamed skin over the tuberculous gland
whose contents are liquefied, may perish, and form a dry parchment-like
slough, very slowly to be detached. More commonly, however, one or
more small ulcerated apertures form in the skin, and let out the fluid. If
the undermined skin be freely cut, its loose edges are apt to ulcerate
widely ; if it be only punctured and allowed to subside gradually, it usu-
ally contracts and recovers its healthy state.
The cavity left by the discharge of the liquefied tuberculous matter,
and of the fluids mingled with it, may heal up like that of an ordinary ab-
scess, but it does so slowly, and often imperfectly, enclosing portions of
tuberculous matter, which soften at some later, and often at some distant,
period, and lead to a renewal of the process for discharge. However,
such retained portions of tubercle, or even the whole of what has been
formed, and perhaps liquefied, in a lymphatic gland, instead of being dis-
charged, may degenerate further, and be absorbed ; or may wither and
dry up into a fatty and calcareous concretion. Such chalky masses, even
of large size, are frequently found in bronchial and mesenteric glands,
that have been seats of tuberculous* disease in childhood ; and similar
material, but usually in small fragments, is often discharged from healing
tuberculous abscesses in the neck.
Whether by healing after discharge, or by calcification of the retained
tuberculous matter, the recovery from the primary tuberculous disease of
the lymphatic glands is often complete and permanent. The original
substance of the gland may be wholly destroyed ; or portions of it may
remain indurated and fixed closely to the scar or the calcareous concre-
tion.
I am not aware that tubercle is ever seen, primarily, in lymphatic
vessels ; but it may be often traced in those of the intestines and mesentery
680 TUBEBCULOUS ULCEKS OF THE INTEGUMENTS.
that are in relation with tuberculous ulcers involving the muscular and
subperitoneal tissues.
I am not aware that tubercular deposits have been proved to be tie
origin of the so-called scrofulous ulcers of the integument ; but that tbe?
are so is highly probable, seeing that such ulcers sometimes supervene it
the openings for discharge of liquefied tubercle from lymphatic glanis
and that, in many characters, they remarkably resemble the tuberculou
ulcers of the mucous membrane of the intestines.
The ulcers for which we may suspect a truly tuberculous origin are m^ift
frequent in the neck, at the sides of the face, at the up(>er part of the
chest, and on the arms. They are sometimes preceded by the fonuatioD
of one or more small oval masses of firm substance in the subcataDeou
tissue : these, passing through the usual changes of suppurating tuUt-
culous glands, discharge themselves ; and the ulceration extend:^ from
the aperture of discharge. But, more often, the ulcers commen<y in
patches of skin which, with the subcutaneous tissue, have appeared, fur
some days or weeks, inflamed, thickened, and slightly indurated. Cen-
tral softening and liquefaction ensue in these ; the cutis is gradnailj
undermined, and then ulcerates, letting out a small quantity of thin,
flaky, and turbid fluid, like that of liquefied tubercle. The ulcers thus
formed have generally destroyed the thickness of the cutis. Tliey are
of various shapes ; most often elongated oval, but sometimes round, or
sinuous ; more rarely annular or crescentic ; very rarely (juite rt.*;nilar in
shape. Their margins are usually (if they are not quickly extending)
undermined, rounded, thickened, and unequal. The skin upon and arc»aiid
their margins is pale rose-pink ; or tends, according to the activity ••r
torpor of the disease, towards florid redness, or a pale livid hue. Thvu
bases are unequal, often nodular, or tuberculated, pale, with unequal or
succulent granulations ; they yield a thin, turbid, whey-like fluid, which
may concrete in scabs, and sometimes irritates the parts on which it
lies. They have no proneness to extend much in depth : neither do tbey
extend widely, unless acute inflammation supervene at their boundarit*^;
rather, their tendency is to remain long stationary, or partially healing:
or, while some are healing, others may be progressive.
The scar formed in the healing of these ulcers is peculiar, resemblinf^
that of the healed tuberculous ulcers of the mucous membrane of the
intestines. It is formed of very tough tissue, which remains long fixiil
to the subjacent structures, and of which the surface is generally colore*!
with vascular congestion, seen through the thin covering of new cuticle.
But, chiefly, the surfaces of such scars are deeply seamed and wrinkK^l ;
or have prominent hard ridges that tend towards their centres, or acr^c^
their axes. The cutis that surrounds Uie ulcers is very much contracted
in the formation of the scars : and both in this respect, and the abundant
tough tissue constructing them, they may be likened to the scars follow-
ing bums.
I
TUBEBCULOUS DISEASES OF BONES. 681
Among the Bones, tuberculous disease affects most frequently those of
spongy cancellous tissue ; such as the tarsal and carpal, the vertebrae,
the phalanges, and the expanded articular portions of larger bones, espe-
cially of the femur, tibia, humerus, and ulna. When it affects bones
that are arranged in a group or series, it is usually found in many of
them at once. Thus, several vertebrae, or several carpal or tarsal bones,
are commonly at the same time tuberculous ; yet not often so equally, but
that one of them appears first and chiefly diseased; while, in those
gradually more distant from it on either side, the tuberculous deposits
are gradually less abundant. In like manner, the parts of bones that
act together in a joint are, usually, at the same time tuberculous.
Rokitansky says that gray tuberculous matter may be found, about
tuberculous suppurations in bone, in the form of granulations seated in
the medullafy membrane. The usual appearance is that of yellow, soft,
cheesy deposits, or infiltrations of tubercle. The infiltration may be
either circumscribed or diffuse : and, in these differences, generally cor-
responds with the similar varieties in the lungs ; especially in that,
usually, the circumscribed infiltrations take place with scarcely any signs
of inflammatory disease, while the diffuse are preceded and accompanied
by all the signs and effects of slowly progressive inflammation of the
bone.
In the circumscribed infiltrations, the tuberculous matter usually forms
round, or oval masses, which are imbedded in cavities in the interior of
the bones. At these cavities, several of which may exist near together,
the normal textures of the bone appear to be disintegrated or absorbed,
just as those of the lung are during the infiltration of the tuberculous
matter among them. When the liquefaction of the tubercle takes place,
a similar imitation of the formation of cavities in the lungs is noticeable.
The usual thin puriform fluid is produced, and is often mixed with little
fragments of bone. The bony cavity including it commonly becomes
lined by a thin, smooth, closely adherent membrane, — the product,
apparently, of ordinary inflammation. Appearances are thus attained,
especially in the bodies of vertebrae, like those of numerous small chronic
abscesses in bones : and similar cavities may be found between the bone
and periosteum, when the tuberculous matter has been formed between
them, or has included the surface of the bone in its infiltration. The liquid
contents of the cavities may be discharged through narrow apertures in
the walls of the bone or other surrounding parts ; but, commonly, a more
diffuse inflammatory or tuberculous formation ensues, destroying both the
walls of the cavities and their boundaries.
The diffuse infiltration of tuberculous matter in bone may be the form
assumed from the first, or it may supervene on the preceding.* The
deposits observe no definite shape : they fill the cancellous spaces in the
* The two forms are illustrated in the College Museum, No. 854-5; and in that of St. Bar-
tholomew's in Series I. 37, 38, 39, 70, 108, &c.
682 TUBERCULOUS DISEASES OF BONES.
bone, displacing the medulla, and either leaving the osseous tissue entire,
or softening and disintegrating it, so that small fragments, or lan^r
sequestra, appear mixed with the crumbling tubercle. The abuii>liDt
deposit of tubercle, and the fulness x)f the vessels of the inflame<l loA
softening bone, make the swelling in this form more considerable than in
the preceding ; yet it is rarely, if ever, great. The liquefaction is ai-
tended with larger and more destructive, though slow, ulceration of tiie
bone ; and is followed by discharge of the fluid, together with pro<luctt
of inflammation, through many apertures, or from a wiilely ulcoratdl
surface. The bone bounding such ulceration is, moreover* commoniT
inflamed, if not tuberculous ; and thus the ulceration may con5tan:lj
make progress in depth and width, imitating the types of tubt*rciil(*u
ulceration already described, in that the destruction is of two-fold chan^
ter : due partly to secondary formations and liquefactions of tubercle, and
partly to continued bordering inflammation.
The changes produced by circumscribed tuberculous deposits in U^m
are, comparatively, seldom seen ; for the disease is of slow j)ropnes«. and
rarely leads to death, or amputation, before the more diflfuse ulceraii»«
has supervened and destroyed its characteristic features. The diffuse
disease is therefore that which has been most studied, and which haii ^ufp
plied most of the examples of "scrofulus caries,** *' Pott's di.^oase **( the
spine," " Piedarthrocacc," &c. It is this, also, which is chiefly atton-l"!
with suppurations, or, perhaps, tuberculous deposits, in the neighborh-il
of the diseased bone.
The tuberculous diseases of bone are, comparatively, rarely htaK'^l
Mr. Stanley has well shown that the completely curable cases of *•^^T'*•
fulous'* disease in bone are those in which "the changes have n<»i pa>M-l
beyond those of simple inflammation:** i. r. of such inflammation a:? o-n-
monly precedes the diflusc deposit of tubercle. When tubercle is •Ir-
posited in bone, its usual course is, as in other parts, only de;reneraiiu-:
it may litjuefy, or calcify: it is, probably, never organized or a^^•'r•^♦l.
Calcareous concretions, that had their origin in tuberculous matter, mav
be found imbedded in or upon bone, enclosed in indurated ossei»u« ■•:
periosteal tissue ; but they are, I believe, extremely rare. Healin;: ••£
tuberculous cavities and ulcers in bone is less rare. No new Inme mav r*
formed; but the membrane lining a cavity may become thick and tough:
its contents may become denser and dryer ; and the bone for a short
distance around it mav be hardened and solidified ; and all the mi>rli;>i
process may cease. Or, the surface of an ulcer may gradually hea! :
compact hard bone forming on it, and combining with the thick au«l
scarred periosteum and superjacent tissues. Or, lastly, though rarrly
after tuberculous disease, when two ulcerated surfaces of l>one come into
contact, they may unite and coalesce : as in the anchylosis which may
ensue after tuberculous ulceration of the articular portions of bones or
between vertebrae, in some of the cases of tuberculous disease of the spine,
TUBEUCULOUS DISEASES OF BONES. 683
or among the bones of the carpus or tarsus. In all these instances, it
may be generally observed that, as inflammation of the bone preceded
and bordered the tuberculous deposits and ulcers, so, when healing
ensues, the bone adjacent to the scar or carity is hardened, pale yellowish
white, less vascular than in health, and made heavier and more nearly
solid by the thickening of its cancelli.
The instances of tuberculous disease which have now been described
may suflSce, I hope, for all that I can have in view ; namely, the illustra-
tion of the general characters of the disease, and the principal facts on
which to form an opinion concerning its nature and affinities.
On first thought, there may seem little right to assume such a relation
between tubercles and tumors, as is implied by their inclusion in this
volume : yet the features of resemblance are not few or inconsiderable.
The question, broadly stated, is whether tuberculous diseases have nearest
likeness to inflammations, or to cancers.* It is a very difficult one to
answer, for there are apparently good arguments on both sides. On the
whole, I am disposed to think that the really tuberculous diseases are
more, and in more significant things, like the cancerous than they are like
any others. Therefore, I have spoken of them here, and have arranged
the illustrations of them in a corresponding place in the College Museum.
But I will now state both sides of the question.
I. The likeness between the tuberculous diseases and the inflamma-
tions, with lymph products that are least capable of development, seems
to be shown in these things : —
(1) The likeness between tubercle and such lymph-products is often
too great for diagnosis: they have been, and are, often confounded: and
the withered and degenerate nuclei and other particles of which tubercles
are chiefly composed are, at least, as much like those of degenerate in-
flammatory lymph as they are like any other morbid products.
(2) Inflammation, indicated by all its signs, is a common precedent
and attendant of tuberculous deposit. It evidently exists in nearly all
cases of the acute, and in many of the chronic, tuberculous afiections of the
glands, lungs, and other parts ; and inflammatory lymph capable of com-
plete development is sometimes mingled with tuberculous matter.
(3) The degenerations of tuberculous matter are, in all essential points,
parallel with those of inflammatory lymph : and so are the processes
preceding and following the discharge of the liquefied product.
* The observations of Virchow and Schroeder van der Kolk, respecting the formation of
tuberculous matter in epithelial cells and other natural tissue-elements, are not opposed to
this mode of stating the question. It may be said that there are many points of resemblance
between tuberculous diseases and the degenerations of parts; but it would be a very far,
and, I think, a very injudicious, extension of our ideas of degenerations, to include the pro-
cess for the formation of tubercles among them. The differences between the tuberculous
disease and all the natural processes of merely defective nutrition separate it widely from
all degenerations properly so-called. The tuberculous material naturally degenerates; but
its production cannot be reasonably called a process of degeneration in any normal part.
684 AFFINITIES OF TUBERCULOUS DISEASES
(4) The same constitutional peculiarities (so far as they can be iV
8er>'ed) precede and attend the tuberculous diseases and the Hvcallfd
scrofulous inflammations, which are not productive of tuberculous depn^hs.
Whether, therefore, we consider the local or the constitutional (an^ of
the process, there may seem no boundary-line, no mark indicating;: i-xhtd-
tial dissimilarity, between the tuberculous diseases and the inflammaitioos
producing lymph nearly incapable of development. The ctmcla^iim,
therefore, might be, that the local disease is a specific inflammation, Je
pendent on a peculiar diathesis or constitution of the blood, ami to he
studied according to its analogies with gout, rheumatism, syphilis, ami the
constitutional affections that are manifested by local inflammati<«5.
On the other side, it may be said, — (1) that the likeness hi^twMi
tubercle and degenerated lymph is only that into which a lar^ mm*
ber of both normal and morbid products merge in similar dep^Ufn-
tions ; (2) that the coincidence of inflammation and tuberculous dep^it
is accidental and inconstant, and that the mingling of the dovt^loi'ln;
products of the one, with the degenerating material of the other, pn^vrt
their essential difference ; (3) that the same methods of degoninti/D.
and of disposal of liquefied materials, which are observed in tubercle a&d
aplastic lymph, may be noticed in other products, — for instance, m
cancerous and other growths with ill-developed structure; and (4) that
the similarity of the constitutional states only justifies the exprcs**iini,
that "scrofulous" persons are peculiarly liable to tul)erculous, as well as
to inactive inflammatory, diseases.
II. The chief grounds for regarding tubercle and cancer as diH?a<e«
of the same order are the following : —
(1) Tubercles sometimes appear as distinct masses, like tumors, in th^
brain, and in other instances of so-called encysted tubercle. And the
dissimilarity between these and tumors, in that they neither gn»w !t
inherent power, nor are vascular, is only because their elementary «t^I^
tures abort, and very early become degenerate ; it is only the same •li*-
similarity as exists between a degenerate, and a growing, mass of camxT.
(2) The general characters of malignant tumors, as deiluceil from can-
cers (p. 324), are also observed in tuberculous diseases : namely, the ele-
mentary tuberculous structures are heterologous ; they are usually infil-
trated, and, at length, exclude, and occupy the place of, the natural
textures ; they have a peculiar tendency to induce ulceration after s^»fteii-
ing ; the walls of the ulcer are commonly occupied by tuberculi»us Jcjio-
sits like those which preceded it, and, while thus occupied, have no JL-jkh
sition to heal ; the tuberculous deposits apparently multiply in all the
same manners as the cancerous do (compare p. 600, e. s.) ; and, whether
in their extension or in their multiplication, there is scarcely an orpin
or tissue which they may not affect, though, like cancers, the primary
tuberculous diseases have their "seats of election,** and different seat* at
different periods of life.
TO INFLAMMATION AND GANCEB. 685
(3) The tuberculous diathesis, the constitutional state which precedes
the formation of tubercle, is scarcely producible by any external agencies,
except climate ; but it is frequently hereditary : and in both these re-
spects it resembles the cancerous, and differs from the merely debilitated
state in which the aplastic inflammations occur.
(4) The cancerous and the tuberculous diathesis appear to be incom-
patible and mutually exclusive : the production of tubercles is extremely
rare, but that of lowly organized inflammatory products is frequent, in
cancerous patients. Such incompatibility implies that cancer and tubercle
are equally, and in the same sense, constitutional diseases ; very different,
yet of the same order in pathology.
(5) The tuberculous diathesis, like the cancerous, regularly increases,
and is attended with cachexia, which is often disproportionate to the
local disease. It is true that tuberculous disease frequently ceases in a
part, and allows its healing ; yet if we look to its enormous mortality as
the index of its natural course, we must see in it a law of increase, like
that exemplified with fewer exceptions in cancers. And such a law
is not usually exemplified in the specific inflammatory diseases ; for they
generally tend to subside with lapse of time.
If, now, I leave the reader to consider for himself the question that
may thus be argued,. I shall but fulfil a purpose kept in view in all the
lectures — the purpose, namely, of offering materials for thought upon
subjects of which I have not knowledge. It will be within the same
scope if I suggest a contemplation of the seeming opposition between the
chief subjects of the first twenty, and the remaining lectures in this
volume.
In all the affections considered in the former, we may trace purpose and
design for the maintenance and recovery of the body's health. The
strengthening against resistance, the reaction after injury, the turbid
activity of repair, the collection and removal of inflammatory products,
the casting of sloughs, the discharge of morbid materials from the blood,
— all these are examples of the manifold good designs of disease ; and
they evince such strength and width of adaptation to the emergencies of
life; that we might think the body was designed never to succumb before
the due time of its natural decay.
But in the diseases considered in the latter, we trace no fulfilment
of design for the well-being of the body: they seem all purposeless or
hurtful : and if our thoughts concerning purpose were bounded by this
life, or were only lighted by the rays of an intellectual hope, we could
not discover the signs of beneficence in violences against nature, or in
early deaths, such as I have here described. But, in these seeming oppo-
sitions, faith can trace the Divine purposes, consistent and continuous,
stretching far beyond the horizon of this life ; and among the certainties
of the future, can see fulfilled the intention of the discipline of siifferings
686 CONCLUSION.
that only death might mitigate. And, if we cannot always tell what
is designed, for themselves, in either the agony or the calm through which
we see men pass from this world, and cannot guess why, for their own
sakes, some are withdrawn in the very sunrise of their life, and others
left to abide till night; yet, always, God's purpose, for our own good,
may be clearly read in the warning, that untimely deaths should make
us timely wise.
INDEX.
A.
Abernethy, Mr., on classification of tumors,
332 ; on pancreatic tumors, 467.
Abscess, formation of, 249-255 ; opening of,
264 ; in bone, 261.
Absorption ; preceded by transformation, 50 ;
of bone, 170; of degenerate parts, 50; of
blood, 123; of bloodvessels, 263; of cancer,
663 ; of dead tissues, 302 ; of inflamed parts,
261, 270; of inflammatory lymph, 244, 246.
Adhesion, primary, 134; secondary, 137.
Adhesions, formation of, 233.
Adhesive inflammation, 135, 218.
Adipose tissue, increased formation of, 33:
and see Fat.
Adipose tumor: see Fatty tumor.
Affinity, elective, in parts, 52, 55.
Age, as affecting repair, 109; general relation
to cancer, 642 : and see Cancer.
Air, cysts containing, 339.
Albuminous sarcoma, 416.
Allocation of cancers, &c., 545, 647.
Alveolar cancer : see Colloid.
Amputation, healing after, 137, 158.
Anchylosis, followed by atrophy, 96.
Aneurism : of bone, 48o ; by anastomosis, 478 ;
effects of pressure by, 71 ; Hunter's opera-
tion for, 38.
Antlers, growth of, after castration, 35.
Antrum, osseous growths of the, 463 ; polypi
in the, 380; teeth in the, 373.
Aplastic lymph, 243, 675, e. s.
Apoplexy, with degenerate cerebral and pul-
monary vessels, 102.
Arachnoid, organization of blood-clots in the,
121.
Arcus senilis, 105.
Arrests of development, 18.
Arterial vascular tumor, 482.
Arteries, contraction of, 182 ; degeneration of,
100; heating of injured, 181 ; obstruction of,
inducing mortification, 38, e. s. 292 ; indu-
cing degeneration in cancers, 664 ; ulceration
of, m progress of cancer, 577 : and see Blood-
vessels.
Artery, femoral, traversing a tumor, 440,
note.
Ascites, fibrine exuded in, 281.
Assimilation, 19; of blood, 26; in diseased
parts, 46 ; by cancer, 659.
Assimilative force, 51.
Asteriae, repair in. 111.
Atheromatous*afiection of arteries, 100.
Atrophy, 72, e. s. ; from pressure, 70 ; modes
of, 72 : see Defeneration ^ of cancerous parts,
653 ; distinguished from inflammation, 279.
Auditory passage, polypi in, 380.
Auricle, cysts fasciculated like an, 348.
Autogenous cysts, 335.
B.
Balv, Dr., on ulceration, 272.
Barky warts, 594.
Barlow, Mr. W. F., on paralysed muscles, 89 ;
on fatty degeneration, 82.
Bats, circulation in the wings of^ 197; their
temperature, 197; rhythmical contractions of
veins, 198.
Baum, Prof, on teeth in the antrum, 373 ; on
aural polypi, 381.
Bell, John, on aneurism by anastomosis, 478.
Bell, Sir C, on cancerous cachexia, 522.
Bennett, Dr. J. H., on fibro- nucleated tumors,
419; on cancroid disease. 564; on inflamma-
tion, 289 ; on blood in inflamed parts, 20is.
Birkett, Mr., on mammary cysts, 343 ; on
mammary glandular tumors, 468.
Bites, &c., venomous, 312.
Blastema, extension of disease along, 660.
Blastema, nucleated, its development, 128:
see also Nucleated Blastema.
Bleeding: see Hemorrhage.
Blisters, different fluids in, 220.
Blood, absorption of extravasated, 123 ; accu-
mulation inducing growth, 59; assimilation
by, 26 ; in cancerous persons, 634 ; initiating
inflammation, 282; death of, in dead parts,
300 ; defect and disease of, inducing mortifi-
cation. 292, 296; effusion in inflammation,
215; effused, supposed origin of tumors,
529; extravasatea, in wounds, its disposal,
120, 122; in inflammations, 205; influence
on inflammatory products, 219; in vessels of
inflamed parts, 194; life of, 27; maintenance
of morbid state of, 47 ; materials of, deter-
mining formation, 33 ; morbid materials in,
27, e. s. ; organization of, 120, e. s. ; in tied
arteries, 184; regular supply for nutrition,
37 ; right state oCfor nutrition, 26, 27 ; clots,
softening of, 243; stagnant after injuries,
139; transference of cancers, &c., by, 662.
Blood-cells, length, &c., of life, 25; develop-
ment of, 51 ; in inflammation, 205 ; white,
on wounds, 137.
Blood-scabs, 152.
Bloodvessels, absorption of, 263; adaptation
to atrophy, 87; atrophy of, 100; initiating
inflammation, 281 ; of cancers, 533, 656 ;
enclosed by cancers, 532, 558; cancerous
ulceration of, 577 ; contraction on stimulus,
499 ; in granulations, 450 ; enlarged in grow-
ing parts, 359; in inflamed parts, 194; for-
mation of new, 144, e. s. 238, 656 ; obstructk>n
of: see Arteries; office of, in nutrition, 40 ;
relation to organization, 149 ; growth of, in
tumors, 485; supplying tumors, 375, 656;
in erectile tumors, 480.
Boils, sloughs in, 296,
Bone, abscess in, 261 ; absorption of, 171, S61;
688
INDEX.
aneurism of, 486 ; atrophy of, 85, 95, e. 8. ;
cancers of, 200, 207, 235, 315 ; cancerous ul-
ceration of, 279 ; cartilaginous tumors on
or in, 120, 131 ; degeneration of, 96, e. s.
267; fibrous tumors on or in, 40<'> ; granu-
lations on, 128, 138, 139 ; hypertrophy of, 64 ;
inflammation of, 236 ; lengthening of, 66 ;
myeloid tumors on or in, 446 ; in aecrosis,
301 ; nutrition of, 40 ; scats of osteoid can-
cer, 613 ; pus from, 271 ; serous cysts in,
340, note ; softening and expansion of, 258 ;
tubercle in, 681 ; ulceration of, 271, 681 ;
under cancerous and other ulcers, 327 ; for*
mation of, in cartilaginous tumors, 427,429;
in fatty tumors, 378; in tibrocellular tu-
mors, 384 ; in tibrous tunH)rs, 400 ; in inflam-
mation, 456; in inflammatory lymph, 235;
in labial glandular tumors, 476 ; in myeloid
tumors, 447 ; in osseous tumors, 466, 457 ;
in osteoid and medullary cancers, 466.
Bowman, Mr., on healing of wounds in the
cornea, 288.
Brain, adaptation of skull to, 65, e. s. ; atrophy
of, 103; bloodvessels of, in rod softening,
196; cysts in, with fat, hair, &.C.. 369; de-
generation of minute vessels of, 100; efiects
of its diseases on the cord, 104 ; of idiots. 18 ;
effects of exercise, Slc, ^ ; penetration by
ulcer, 327; sloughing of, 38; softening of,
103 ; tubercle in the, 684.
Brain -like epithelial cancers, 570.
Breast : cancer not afleciing fflandular tumors
in the, 473; cancer of the. following the ex-
cision of glandular tumors, 473 ; hard can-
cer of the: see Scirrhous Cancer; healing
after removal of, 132; induration of, influ-
enced by the mind, 41; irritable tumor of
the, 396; malignant fibrous tumor in the,
409 ; medullary cancer of, 546 ; myeloid tu-
mor in the. 454 : see also Mammary Glnnd.
Brodie, Sir B. C, on fatty outgrowths, 374, ;
and tumors, 375 and 648; on mortitication,
294, Slc; on serpent poison, 312; on can-
cerous tubercle, 5^^.
Brood -cells in cancer, 580.
Brow : cysts near the, 369.
Brown* Sequard, M., on repair of spinal cord,
188.
Bruch, Dr., case of cancer, 631 ; on multifor-
mity of cancer-structures, 423.
Budd, Dr. W., on symmetrical diseases, 28.
Bursas, 345; with endogenous growths, 353;
under corns, 57,70.
C.
Cachexia in cancer, 667.
Calcareous deposits in fibrous tumors, 402.
Calcareous degeneration of bloodvessels, 100;
of lymph, 244, 247; of cancer, 664; of tu-
bercle, 673, 682.
Callus : SCO Repair of Fractures.
Cancellous osseous tumors, 457.
Cancer : general pathology [for special patho-
logy, see the specific names, Scirrhous, dec]
Hypothesis. G3^; constitutional and specific
disease, 632 ; preceding conditions, 632 ;
morbid material in the blood, 632; appro-
priate part, 606; necessity of their coinci-
dence, 633; and of considering it, 633;
cases, 634. N ature of the cttmeenfuiblood, 636 ;
cancerous particles in it, 637; chemistry.
637; incompaiibiliiy. 637; mri}ii»i U .*•
production. (}38 ; by mheh»anr#-. •..'.•; rr.<-
fication therein, 640; intx-ulaMon. *A*j. 'i-
vorable conditions of sex. (i-lJ; mi^t •■(:.
constitutional degeneracy. tA'A: r-.fu'«.
644 ; mental distress, 614; inrreif^ ol -i--
cerous diathesis, 645; su«»p.-n«iti[). 64^: ?x>
dification, 646; supersession. 64«i Ajt'»-
calitjf^ 646; most and Icsjir trt-q^'tit «fi*.
647; allocation. 647; liability nt tn'irf:
tumors. 647; whence supptMrd. M*: v-
auired aptness. 649; congenitsi detrn. •»(>.
iscase. 649 ; injury. 649 ; rule thrrvrt or-
rived, 6.')0.
Cancer-structures, questions of tranvhrtst-
tion, 651; const ruction, 6.iJ; i-",":! n »<.
653; changes in afllecied part. t»M: t>»>
tema, 653; primary cell-forms. t.j.i;e4(-
nosts, 654; multiformity. 6.%4 ; nHiVif'n;^;
with normal tvpes. 655 ; stroma. <«>» ; bkH4<
▼essels, 656; chemistry. 6.'>7: litr. i* iT; i^ma-^
658; two ministrant cmidiiHins. < 5** ; lJi-4>itri
cancer, 659 ; extension. 6m) ; in lympu- a.
660; multiplication, ii4>l ; by conac:. t*^!.
on continuous surfaces. 4a\\ ; in croupt. **>> :
to distant pans. 661 ; by incrraviri; dirv-
sis. 662; by transferem^c in hUmd. t^^i; x-
generations, 664; diseases. tin5; «ir(<*^
6<>5; ulceration, fi4i6 ; constii ai ions' rf'<'i,
666; primsry and secrmdsry carhrs;s.'**.
effects of removal. 667; nosology. ««67; 'JU-
ness of tubercle to. ti84.
Cancerous growths in cysts, 367; disrsM it
erectile tumors. 4.'"9: and csrtiitf>sj
tumors mixed. 444 ; following theexci*^i«l
mammary glandular tumors. 47J.
Cancerous parents: tumors in the rhildrrtflt
474.
Cancroid. 564.
ulrer. 588; of the face. 50*.
Canton, Mr., on the arena seniUii. 105.
Capillary vancular tumors. 4*^1.
Cspsulctf, Ismmated. 5iM) ; investing tsajn.
«> 1 .1 .
Carcinoma fasciciilatum seu hyaltnam. •«>■.
Hbrosum. 500, 510; reiiculare. 490. if^ w*
Cancer.
Carpenter, Dr., on defective nutrition oi f-
flamcd parts. 258; on epidemic*. 3'.^. •<
the individual lite of parts, 21. note; on ui.
and physicsl forces. 53.
Csrtilagc, repair of, 174 ; inflsmmathm &i J- 7.
269; increase in inflammation. 237; ulrvrv
tion of, 271 ; in fibro-cellular tumor*. .^^
Cartilaginous tumors: general seat*. 42! . <*•
or in bones, 422; consiructiOD. 422 ; in'oir.
422 ; microscopical structure. 423 ; ol b»»s>
423; of cells, 424; of nuclei. 425; ^rvrnt.
427; size. 428; ossification. 429 ; defrrjtn-
tion or defect, 430; softening, 4J0; m»»
431 ; case of extreme softness. 4J1 ; twjfft*
ing and suppuration, 433. Of the locx
bones, 434 ; of the jaws, 436; ol' fhr •kt»
and vcrtebre. 436; of the hsnds, 4.17: bf
the psroiid and sub-maxiUsry glsndt. 44i'
Ctcnersl nature. 4 42 ; recurrence, 443; wrf-
ditsry, 443; conjunction with cancer. 444.
and with other tumors.445.
Castration, effects of, on antlers, &,e.. 35.
Catalytic action of dischams, 27J.
Cauliflower excrescence ol uterus. 506.
Cavernous tumors, 478.
Cavities, tubercuioua, 674, 679, 661.
INDSZ.
689
Centres of ossification, hypertrophy at, 65.
Cerebriform cancer: see Medullary Cancer.
Chancre, lymph in, 234.
Channelling of bloodvessels, 147.
Chemical composition ; relation to vital acti-
vity, 144
Chemical changes in granulations, 144.
Chimney-sweep's cancer, 595; and see Epi-
thelial Cancer.
Cholestearine in cysts, 242, 371.
Cholesteatoma, 371.
Chondroma, 421, note.
Chorion, cystic disease of, 356.
Chronic mammary tumor, 467 .
Cicatrices ; see Scars. Cancer of, 589.
Climate ; relation to cancer, 644.
Clitoris, cancerous cysts in the, 378; out-
erowth of. 381.
Clot ; see Blood Clot.
Coaeulable lymph, 2}6 ; see Lymph.
Cold, producing modification, 294.
Colloid cancer ; general characters, 625 ; man-
ner and extent of growth, 626; mingled,
626; minute structure, 626; analysis, 627;
relations to other cancers, 628 ; general re-
lations of cysts to cancers, 629 ; general his-
tory of, 621 ; likeness to cartilaginous tu-
mors, 431.
Colloid cysts, 349.
Coilonema, 379.
Common disease, 303.
Complemental nutrition, 34 ; in disease, 37.
Compound cvsts, 352.
Concurrent development of organs, 36.
Conditions^ nutrition : see Nutrition.
Congenital defects ; liability to disease, 610,
649.
excesses; contrast with tumor8,322,
note,
hypertrophy, 60.
^ Congestion, active, 199, 306 ; mechanical, rela-
tion to inflammation, 282.
Conglomerate tumor, 440, note.
Conical Clot, 184.
Conjunctiva, inflamed after stimulus of retina,
208, 286.
Connective-tissue tumor, 379.
Constitutional disease, 306, e. s. ; see Specific
Diseases ; become local, 659 ; in cancer,
666.
Contraction of organized inflammatory pro-
ducts, 234.
Cooke, Dr., case of recurring mammary pro-
liferous cysts, 366.
Cooper, Sir A., on chronic mammary tumors,
468; on irritable tumors of the breast, 396.
Coote, Mr., on vascular tumors, 483, 488.
Cord, spinal, consequences of injury, 42, 44 ;
atrophy of, 104.
Corns, 69 ; bursa under, 58.
Cornea, fatty degeneration of, 105 ; effects of
inflammation of, 268 ; ulceration of, 42.
Corpus fibreux, 399.
Corpuscular lymph, 217: see Lymph.
Corrosive properties of discbarges, 273.
Cowperian cysts, 346.
Cranium : see Skull.
Croupous lymph, 216 ; 670, &c.
Crystals, repair of, 108.
Curling, Mr., on atrophy of bone, 110; of
scrotal cancer, 568, 601.
Cutaneous out^owths, 381.
proliferous cysts, 368 : with perfect
44
skin, 368 ; in the ovaries, 368 ; in the subcu-
taneous tissue, 369; in various parts, 369.
Cuticle, life of, 24 ; thickening of, 70 ; formed
on granulations, 142; separating over ab-
scess, 265.
Cuiicular cysts, 370.
Cysts or cystic tumors, 333 ; primary and se-
condary, 334 ; mode of origm, 334 ; general
structure of, 325 ; modes of development,
336; their various contents, 358; progres-
sive changes in, 351 ; degeneration, 351 ;
endogenous formation of, 353 ; with endoge-
nous cancerous' growths, 367; exogenous
formation of, 355 ; with cholestearine, 342;
colloid, 349; compound or proliferous, 342;
connected with Cowper's glands, 345 ; cuta-
neous proliferous, 368 ; gaseous, 339 ; glan-
dular proliferous, 358 ; mammary proliferous,
358 ; mucous, 345 ; containing oily or fatty
matter, 349; proliferous in the thigh and
other parts, 363 ; proliferous, recurring, 364 ;
sanguineous, 347; sebaceous, epidermal, or
cuticular, 370; containing semen or other
secreted fluids, 350 ; serous, 339 ; simple or
barren, enumeration of, 333 ; synovial, 345 ;
containing teeth, 373; with cancer in the
breast, 344; with cancers of glands, 548;
with epithelial cancers, 580: general rela-
tion to cancers, 523 ; in cartilaginous tumors,
431 ; in fatty tumors, 378; in fibrous tumon,
401; in myeloid tumors, 446; in vascular
tumors or noBvi, 341, 348.
Cystic cancer ; see Colloid.
Cystoid growths, 352.
Cysto-carcinoma, note, 368.
Cysto-sarcoma, 368, 352, 470.
D.
Dalyell, Sir J. G., experiments on Hydra, and
'I'ubularia, 112.
Dead parts, separation of, 50.
Death, and degeneration, distinguished, 50,
291 ; natural, of parts, 21.
Decay, natural, of parts, 21 ; see Degeneration,
72.
Degeneration ; general meaning of, 72; natural
occurrence in old age, 73; natural issue of
life, 73; assumed reirogradation of the body,
73 ; design^of degenerations, 74 ; their impor-
tance in pathology, 75; methods of, 75;
withering, 75; tatty, 75; calcareous, 75;
pigmental, 75 ; thickening of primary mem-
branes, 76 ; combinations, 76 ; their occur-
rence before old age, 76: distinction from
diseases, 76 ; general diagnosis, 76 ; relations
with development, 77 ; and with diseases, 78;
liquefaction, 76; conditions of, 84; spontaneous
atrophy or degeneration, 8i6 ; contrast with
hypertrophy, .84.
Degeneration and death distinguished, 50,291 ;
mixed with morbid processes, 24 ; of the
fangs of teeth, 24 ; in inflamed parts, 258,
266; of lymph, 241, 255, 676; of cancer-
cells, 497, 555, 578, 610 ; of tubercle, 673 ; of
cancers, 664.
Dendritic vegetation, 543, 621.
Denti^erous cysts, 273.
Deterioration of parts, sources of, 20.
Determination of blood, 199, 202.
Development; meaning of, 18, 229; separtte
from growth, 18; ajrrestsof, 18; determina-
tion m the order of, 84 ; as part of the forma-
I
690
INDEX.
tive process, 51 ; in hypertrophy, 57 ; con- 1
sumplion of force in, 109 ; checked separately !
from ijrowth, 110; arrest or error ot, in gra-
nutations, 142; congenital excess of, contrast
with tumors, 322, note.
Diseased parts, assimilaiion in. 46.
Diseases occurring only once, 47.
Diseases of cancers, 665 ; of the products of,
143. 256.
Dittrich, Prof., on pulmonary apoplexy, 103.
Dropsies, mechanical, 214; nbnnous, 212, 224.
Duration of life in parts, 24.
Dysentery, ulcers m, 272.
E.
Ear, vascular tumor of the, 482 ; fibrous tumors
in the lobules of the, 407.
Eburnation of bone, 261.
Epidermal cysts; contents protruding, 371;
and becommg[ vascular, 372.
Elastic tissue m adhesions, 235; in fibrous
tumors, 400.
Election, seats of, 29.
Elective affinity in nutrition, 52-56.
Elephantiasis scroti, 381.
Encephaloid : see Medullary Cancer.
Enchondroma, 421, e. s. : see Cartilaginous
Tumor.
Endogenous cells, in cancer, 580.
cysts, 370 : see Cysts.
Epidermis, growth of, 56.
Epidermal cysts, 370.
Epithelial cancer : primary seats, 564 ; second-
ary, 564 ; superficial form^ 566 ; warty and
other external characters, 566 ; distinction
from common wariy growths, 569, 466; in-
terior structure, 564 ; peculiar soft material,
570; papillary and deep-set portions, 571;
infiltrated cancer-structures, 572; stroma,
572; deep'geated Jform, 573; cases, 573; ul-
ceration, 575; microscopic structures, 577;
their arrangement, 582; varieties, 582; me-
lanotic. 582 ; cylindriform, 582; iniermediaie,
583. In lymphatic glands, 583; primary,
585; lunsst 585; hearty 586; uterus and
vagina, 586 ; diagnosis from other cancers
and from rodent ulcers, 538 ; cancer of cica-
trices, 589. Pathology : influence of sex.
591 ; age, 591 ; hereditary disposition, 592;
injury or disease, 594 ; ulcers, 594 ; warts,
594 ; cancer-structures new formed in them,
596; general health, 597; growth, 598;
ulceration, 598 : pain and cachexia, 598 ;
multiplication, 598; variations according to
seat, 600; duration of life, 600; rules for
operations, 601; in cases of recurrence, 602 ;
relations to other cancers, 603.
Epithelioma, 564.
Epithelium, on adhesions, &c., 235.
Epulis, 407, 449.
Erectile tumors, 477, 544.
Erysipelas, suppuration in, 252.
Ethmoid bone, with cartilaginous growth, 436.
Excoriation in inflammation, 270.
Excretion-office of each part, 31.
Excretions, mutual, between organs, 36.
Exercise, effects of, in tissues, 20; inducing
growth, 59; atrophy in defective, 85.
Exogenous cysts, 355.
Exostosis, 456 ; foliated or periosteal, 613 ;
Bpong[y or fungous, 535.
Exudations, inflammatory, 212, 216.
Eye, acute cancer of the, 552 ; medullary can-
cer of, 545, 555, 556 ; melanoid cmncer ot, 609.
Eyelash, life of an, 21.
F.
Face, growths on the bones of the, 462.
Facial nerve, influence on nutrition, 45.
False membranes, 233, 239.
Fat, formed in adhesions, 235 ; in the place of
atrophied muscles, 88.
Fatty degeneration, 79 ; general characters of,
79 ; was'ing of nuclei, §0 ; source of the fattj
matter, 80; imitative chemical changes, 80;
adipocere, 81 ; relation to defective nutrition,
81 ; as in old age, 81 ; two modes of atrophj
in old persons, 81 ; causes of fatty degenera-
tion, 83 ; correspondence with those of wast-
ins. 83; relation to general obesity, 83; of
voluntary muscles, 87 ; of the heart, 91 ; of
the uterus and the aiHooth-fihred muscles,
94 ; of bones, 97 ; of bloodvessels, 99 ; ner-
vous tissues, 103; cornea, 105; lymph, 243,
247, 255 ; of inflamed parts, 266.
Fatty matter, in degenerate parts, 51 ; in the
uterus after delivery. 95.
Fatty tumors: outgrowths, 374 ; in the heart,
374 ; tumors, tissue of, 374 ; its arrangement,
375 ; capsule, 375 ; bloodvessels, 375 ; ma!*
tiplicity, 376 ; seats, 376 ; shifting, 377 ; deep-
seated. 377; growth, 377; diseases, 37d;
causes, 379 ; in emaciated persons, 321.
Femur, lengthening of, 67 ; absorption of neck,
262 ; tumor detached from the, 435 ; fre-
quent seat of osteoid cancer, 619.
Fever, cancer withering in, 638.
Fibrine in lymph, 125; in eflfuecd fluids, 213;
delayed coagulation, 214 ; varieties of, in in-
flammatory exudations, 220; degenarationi
of. 24>.
Fibrinous lymph, 216.
Fibro-calcareous tumors, 402.
Fibro-cellular tissue, development of. 129, HI.
and fibrous tissues, formed from
lymph, 126. 231.
Fibro- cellular tumors. Previous descriptioos,
379 ; Polypi : of the nose. 380 ; antrum. 3i*0;
ear, 380 ; urinary bladder, 381 ; rectum. 3S1.
Cutaneous outgrowths : elephantiasis, 3dl.
Fibro-cellular tumors, general form. &c.,
382; texture, 383; microscopic structure,
383 ; chemical character, 384 ; containing
cartilage or bone, 384 ; degenerate, 384 ;
seats, 385 ; in the scrotum, 385 ; by the
vagina, 387 ; in the limbs, 388 ; in the testi-
cle. &c., 390; general history, growth, Sic^,
390.
Fibro-cystic tumors, 401 ; with cartilage, 445.
Fibroid tumors, recurring, 412, e. s.
Fibro-nucleated tumors; general characters,
419; cases, 419.
Fibro-plastic tumors, 446.
Fibrous tissue, developed horn lymph. 234;
ossification of, in bony tumors, 462 ; fibrous
tumors in or near, 405 ; in cancer, 495. 500.
Fibrous tumors. Polypi : of the uterus, 397 ;
of the pharnyx, 397 ; Tumors, general shape,
398 ; capsule, 398 ; texture, 398 ; plan oi
fibres, 898; vascularity, 399; microscopic
structure, 399; muscular and other mixed
tissues, 400 j cysts, 401 ; calcareous deposits,
402 ; softening, 403 : seats, 403. Subcuta-
neous, 403; protruaing, 404; near fibrous
INDEX.
691
tissues, 405 ; of the jaws, 406 ; in the lobules
of the ears, 407 ; multiplicity, 408 ; growth,
409 ; general nature, 409 ; malignant, 409 ;
of the breast, 467.
Fibula, acute cancer of the, 552; cartilaginous
tumor in the, 434.
First intention, union by, 131.
Forces, actuating the formative process, 52.
Form, organic, dependent on composition, 54.
Food, effects of, in the formation of tissues, 33.
Foot, atrophy of, 71 ; cartilaginous tumor,
437; fibro-cellular tumor in the, 389; fibrous
tumor in the, 405.
Formative force, 53 ; its method, 54 ; hypothesis
concerning, 54 ; illustrated in the repair,
107 ; consumed in organizing, 109.
Formative process; its modes, 17; its preci-
sion, 28, 48; disposal of old particles, 50;
degeneration ana death, 50; instanced in
teeth, &.C., 50; development of new parti-
cles, 51 ; influence of nuclei, 51 ; reproduc-
tion and repetition of parts, 51 ; •likeness to
older structures, 52; nature of formative
forces, 52; theory of assimilation, 52; its
inapplicability, 53; formative or plastic force,
53; 89 in development, 53; its method, 53 ;
dependence of form on composition, 54;
hypothesis, 54 : see, also. Nutrition.
Fractures, share of the blood in repairing, 124 ;
followed by partial atrophy, S.*) ; ununited,
172; spontaneous, in atrophy, 96; in molli-
ties ossium, 97; in cancerous patients, 508:
see Repoir of Fractures.
Frogley, Mr., cases of cartilaginous tumors,
428.
Frog's web, experimental injuries of, 138,
198, &c.
Frontal sinuses, osseous tumors in the, 459.
Fungus hematodes, 612.
G.
Ganglions, 345.
Ganf^rcne : see Mortification ; relation to ulce-
ration, 272.
Gaseous cysts, 339.
Gelatiniform cancer: see Colloid.
Gelatinous polypi, 380.
sarcoma, 379, 440, note.
Genital organs, relations of development of, 35.
Gerlach, Dr., on osteoid cancer, 616; on vil-
lous cancer, 621, 623.
Glands, products of inflamed, 224.
Gland-cells, length of life, 25.
Gland-ducts, involved in cancer, 495.
Gland-growths, intracystic, 322, 358, 361, e.
8. ; outlying, 323.
Glandular tumors: general relations, 467;
mammary, 468; usual seats, 468; shape,
dLc, 469; construction, 469; structure, 469;
microscopic structure, 470; growth, 471;
pain, 471 ; disappearance, 472 ; large size,
472 ; in the male, 472 ; relation to cancer, 4 73 ;
in cancerous families, 474. Labial, 475. Fro-
static, 476. Thyroid, 47&. Mixed, on the
parotid and submaxillary glands, 440.
Globes, ^pidermiques, 580.
Gluge, Prof., on albuminous sarcoma, 416.
Granule-cells and masses, 245, &,c.
Graafian vesicles forming cysts, 353, 368.
Granulations, process of; 137; and see Repair
by granulation ; ossification of, 163; eflects
of inflammation and congestion on, 231 ; of
cancer. 518.
Granulation-cells, 126; on bones, 128.
Growth, meaning of, 19; separate from de-
velopment, 19, 110; its nature, 55 ; various
duration, 55 ; adapted to need, 56 ; hyper-
trophy, 56 ; its rule, 56 ; instanced in cuticle
ana muscle, 56; with development, 57; in
the uterus, &c., 57; conditions necessary,
58 ; conditions inducing hypertrophy, 58 ; in-
creased exercise. 59 ; increased materials for
nutrition, 59; increased blood, 59 ; morbid and
inflammatory hypertrophies, 60; consump-
tion offeree in, 110 ; see, also. Hypertrophy.
Gulliver, Mr., on degeneration of arteries, 100.
Gum cancer ; see Colloid.
Gums, cysti connected with the, 342 ; fibrous
tumors of, 407.
H.
Haematoid cancer, 612.
Hair, life and death of, 21 ; change of color under
nervous influence, 44 ; excretion by, 31 ;
increased growth in afflux of blood, 59 ; in
cysts, 368. e. s.
Hair-follicles ; growth into cysts, 370.
Hands, cartilaeinous tumors in the, 437.
Hannover, Prof., on epithelioma, 564,583, &c.
Harelip; healing after operations, 136.
Hancock, Mr., on fatty degeneration of the
bladder, 95.
Harting, Prof., on growth of muscles, 64.
Hawkins, Mr., on cancerous ulcers, &.c., 5P8,
590 ; on epulis, 407 ; on cystic tumors, 488.
Healing: see Repair; in paralysed limbs, 43 ;
of ulcers, 274.
Heart, atrophy and degeneration of, 84, 85, e.
s. 90; cancer in, 586, 637; fatty degenera-
tion of inflamed, 266 ; fattv growths in, 374 ;
growth of, 55; malformea, 19.
Helniholtz, Prof., on changes in muscles, 20.
Hemiplegia, state of muscles in, 88.
Hemorrhage, arrest of, 181 ; from cancera,
557 ; from fibrous tumors, 404.
Henle, Prof,, theory of inflammation, 286.
Hereditary transmission of properties, 638;
disposition to cancer, 638; disease, trans-
formation in, 308 ; cartilaginous tumors,
443 ; cvsts, 370 ; osseous tumors, 465.
Hernia ; lymph in the sac and intestine, 223 ;
with sloughing, 299.
Herpes, Ivmph of, 247.
Hewett, Mr. Prescott, on membranes formed
from blood-clots, 121.
Hodgkin, Dr., his account of cysts, 353; on
cancer, 622.
Home, Sir E., on vessels in lymph, 240.
Homologous parts, similar diseases of, 30.
and heterologous tumors, 324.
Horns, epithelial cancers like, 568.
Humerus, cartilaginous tumors on the, 434 ;
osteoid capcer of, 620.
Humphry, Mr., on bvpertrophy of muscles,
62; on softening of fibrous tumors, 403 ; on
removal of tumors. 372.
Hunter, John, on effects of pressure, 70; on
hypertrophy of muscles, 61, 64 ; incompati-
ble diseases, 638; on mollities ossium, 97;.
operation for aneurism, 38; on subcutaneous
injuries, 118; on union by first intention,
131 ; on union of granulations, 150; removid
of large tumor, 440.
692
INDEX.
Huxley, Mr., case by, 317.
Hydatid mole, 353, 355.
Hydra, repair in. 111.
Hydrocele. fluid, 213, 215 ; encjrsted, of the
cord, 350; with spermatozoa, 351.
Hydrocephalus, hypertrophy of skull in, 96.
Hydrops fibrinosu8,213.
Hygromata, 339.
Hyperostoses, 456.
Hypertrophy : for seneral history, see Growth.
Of urinary blaclder, 61 ; other involuntary
muscular parts, 61 ; induced by obstacles to
their action, 62 ; growth of fibres, 64. Of
bono : in the skull, 64 ; in hydrocephalus, 64 ;
with shrinking of the brain, 65 : especially
at the original centres of ossincation, 65.
Lengthening of bones, 67 ; with curvature
of the tibia, 67 ; inequality of limbs, 69. Of
cuticle, 70; effects of pressure, 70; from
within and from without, 70 ; occasional and
constant, 70. Of thyroid and other glands,
322 ; of mammary gland, 4ii8 ; of cancerous
parts, 6.'>3; contrasted with tumors. 318;
distinguished from inflammation, 280; in-
flammatory, 224 ; discontinuous and con-
tinuous, 331.
I.
Ichor, 274.
Idiot's brains, 18. '
Imbibition, by parts in nutrition, 39.
Immediate union, healing by, 120, 131.
Impairment of parts, sources of, 20.
Inaction, or incubation, after injury, 138, 309.
Incompatibility of cancer and other diseases,
637, 685.
Incorporation of materials of the blood, 33,
309.
Incrusicd warts. 594.
Incubation of disease, 309, 316, Slc.
Infiltrations, general characters of, 325, 331.
Inflammation, phenomena of : transitions to it
from normal nutrition, 192 ; altered supply
of blood, 193 ; enlargement of vessels, 193 ;
method of, 194; gorging with blood, 194;
incr-'osed redness, 195 ; appearance uf new
vessels. 195 ; changed shape of vessels, 196 ;
changed movement of the blood, 197 ; ob-
served in bats* wings, 198 ; contraction ot
stimulated vessels, 198; subsequent dilata-
tion, 198 ; adapted movement of the blood,
199 ; efl*ects of various stimuli, 199 ; pro-
ducing determination of blood, 199; retarda-
tion of blood, 200; stagnation, 200; obser-
vations in bats' wings, 200; summary of
changes in the blood and vessels, 202 ;
nun-coagulation of the stagnant blood, 203;
causes of the changed movement of the
blood, 203. Changed composition of the
blood, 205 ; change in its corpuscles, 20.'>.
Changed nervous force, 208; ** excitement,"
208 ; transferred disturbance of the force. 208;
cases of this, 208. Changed state of the in-
flamed part, 209. Recovery, 211. Products
of inflammation: Srrum, 213; containing
fibrine, 213; delayed coagulation, 213; dis-
tinction from fluid of mecnanical dropsies,
214. Bloody 2\5; frequency in pneumonia,
215; blood-stained lymph, 215. Lymph,
216; flbrinous, 216; corpuscular, 217;
lymph-corpuscles, 217; their developments.
dec, 218; mixed lymph. 218; relations 'o
organization, 218; plastic and aplattkir %k<-
ties, 218; relations to adbcsivr vA »a(>,':-
rative inflammation, 219. Inducnrc ot ti>>
blood on inflammatory lymph. 219; oStcr«f<
in the effects of blisters, '2^0. Intiitr'.xx ••'
tissue inflamed, 221 ; exaiuplts and c\ t?>
tions, 222. Influence uf itv dciircr u: .n*
flammation, 223, 227; mixed lympti iid
normal blastema. 223. 232. Summary o!' i^
fluences determining adhesive ur tujipo*-
tive inflammation, 225. Mucmt, 223: muti
lymph. 226; pigmental cells, 227. Drtrn^
ments of lymph, 227; its indcpecdrrt i.'.f.
228 ; and meaning, 229 ; and rK-ce^urT oiic-
ditions. 230; cessation of inflammatory ;ri
cess, 230; and of passive conj!rfr:i<in, ;.'.'!:
what determines the direction. .Ml ; tjror.i-
tion of adhesions, &.C., 233; ut tiSr«rj9 t.*-
sue, 234 ; its contraction, 2JI; ot t.i.;<-H
tissue, 234; of elastic tissue, 23.*»: r;k.-*tf-
lium, 235.; bono, 235 ; cartilage, 2.tT ; ui-tud-
vessels, 238 ; lymphatii-s. 239; r.«rvr.n tt*.
240; times for development. 2lo. IHie-w.
rations of lymph, 241 ; c«>ndii»Mn* fa^wnnc
242; in Jihrinr, withering, 212; lat:y. .*(:.
liquefaclive, 244 ; resolution, 241; raiL-t-
reous, 244 ; pigmental, 244 ; t« the crfmacin.
withering. 2(5; fatty, 245; abjiorpioi A
granular matter, 247; calcareous. 24T; p|.
mental, 247. Pus: inflammatory sup(>iri-
tion; transformation of lymph into pat.
248 ; relations of inflammatory and rrpare-
tive suppuration, 24^; a/;«rt#«. 249; ;;« for-
mation, Slc, 250; opening. 2f'lt ; r.^roni,-
abscess, 251 ; dijutt suppmratiom, 2^ J; •••
perficial 9uppu ration^ "233', ri'la(io;i «i| piitTO
mucus, 253; relation to abrasion and uk*tri-
tion, 254; degeneration of pu4-ctj«. J.M ;
various contents of chr«>nir ariil r* ■ i;rr»r,;
abscesses, 2.'>4. Dfgenmtttons <*/ o'^'.'^ii
/ym/>A, 2.')5 ; wastiiiff, 2,'>5 ; tatty .ir .j .i i-
reous, 255; pigmental. 25ii ; d>i i- '. . ■ .
hemorrhagoii. inflanuna;i«in(», <V'.. .>
ChaiiKcs in the timues inflamed ; ai. i\ .:•
ous, 2.')7 ; their double houroe. 2.*«"' ; ^y••.*.-
ing, 25*^ ; expansion, 259; a!»*i»rj'i'j«'". -'..
in opening ot abscesses. 2«i3 ; tat'v a<U *"-.■'
degeneraiion<t, 2»»»i ; calcareous. J ■" : p- •
traiion of elements, 2o9. I'leera;:' .*
dependent on inflammation. 2Tu ; tj' i:..: •'
particles, 270; solution of iherii. .'T. : i .<• ,
rosion, 273 ; ichor. 274 ; healing, 274. Ni-
ture and causes of inflammation : nrrtfun
constituents, 27t); quantity of tiutri:.>fl '■
inflammation, 276; ''increajied action." .T.
diminished formative force, 27^; lutihislw
nutrition in inflamed parts. 279. i\i'm»ff.
2H1 ; in changes ot bI(M>d vessel*. C*-!, i
the blood, 2H2; its localization. '2s4 ; in li.f-
turbed nervous force, 286 ; in the »:»:« >-'
parts, 287.
Inflammation leading to m<tnit':t-afKm. .''i
291 ; specific. 303, e. s. ; relatio i to r€^>i:
190; interfering with uni«»n, IJt; :r* ca:-
cers, 665 ; with tubercle, 6'^J. Alc.
Inflammatory hypertrophy, 61.
products; contrasted «.:£: --*
mors, 319.
Injury, inaction after, 138; rngendfr;ni; in-
flammation, 288; killing pans, 291 ; niak;a|
apt for constitutional disease, 2S5, 313; at
cause of tumors, 329.
INDBX.
698
Innocent and malignant tumors, contrast be-
tween, yi4 ; fusion of, 668.
Innocent tumors, general characters of, 328 ;
occasional constitutional origin of, 329; be-
coming cancerous, 549, 647 ; in members of
cancerous families, 593 ; cancerous disposi-
tion fading in, 640.
Inoculable disease, 33, 284, 310.
Inoculation of cancer, 641.
Insects, repair in, 114.
Integuments, cancer of : see Epithelial Cancer ;
tubercle in the, 680.
Intermuscular tissue, fibro-cellular tumors in
the, 389; cancer in, 507, ."531.
Intestines, with gaseous cysts, 339.
Intestinal canal, nypertrophy of, 61 ; hard can-
cer of, 508 ; medullary cancer of, 549.
Intracystic glandular growths, 356, e. s.
Irritation, 192.
Ivory* like osseous tumors, 457.
J.
Jaw, atrophy with anchylosis, 96 ; cartilagi-
nous tumors on the, 436; cysts in front of
the, 342 ; dentigerous cysts in the, 373 ;
fibrous tumors on or in the, 406: ivory-like
tumor of the, 458, 461 ; myeloid tumors on
or in the. 449 ; osseous tumors of the, in
animals, 461 ; osseous growthof the, 462.
Jenner, Dr., on degeneration, 100; on calca-
reous molecules in colloid cancer, 627.
Joints, cartilaginous growths in, 421 ; effects of
inflammation about, 234 ; effects of chronic
inflammation, 237; false, 173; loose bodies
in, 623 ; loose bone in, 71 ; softening of liga-
ments, 260.
Jones, Dr. Bence, on changes of materials of
the brain, 271, 279.
Jones, Wharton, Mr., on the circulation in the
bat*s-wing, 198; on the blood in inflamma-
tion, 206; experiments on inflammation, 1^8;
198, e. s.
Juice of cancer, 495, 532, 542.
K.
Kidney, inflammation in, 269 ; cystic disease
of, 336 ; effect of destruction of one, 33.
Kirkes, Dr., on adhesions of the pericardium,
244 ; on obstruction of cerebral arteries,
103.
Kolliker, Prof., on dilated small bloodvessels,
196 ; on the change of hairs, 23 ; on degene-
ration in the uterus, 95.
Kreatine, in transformed muscles, 50.
Labial glandular tumors, 475.
Labium, fatty tumor in the, 376 ; fibro-cellular
tumors in the, 387 ; outgrowths of, 361 ; pro-
liferous cysts in the, 363.
Lactiferous ducts, dilated into cysts, 343; in-
volved in cancer, 498.
Laminated capsules, 580; cells in myeloid tu-
mors, 453; in epithelial cancers, 580; fatty
tumor, 371. •
Lanugo, purpose of, 32.
Lardaceous tumor, 376.
Larynx, cysts in front of the, 342 ; epithelial
cancer of, 573.
Latency of disease, 809, 315; of cancer, 640.
Lawrence, Mr., on determination of blocid, 203 ;
on fibro-cellular tumors, 379 ; on glandular
tumors, 474, e. s.
Lebert, M., on inflammation, 196, 202, &,c.;
on lipoma, 374 ; on mammary glandular tu-
mors, 468 ; on fibro- plastic tumors, 446 ; on
vessels of cancers, 533 ; on cancer and can-
croid, 564, 591, 627, &c.
Lepoides, 594.
Liebig, Dr. G., on transformation in muscles,
20.
Life of blood, 27. .
Life, individual, of parts, 21 ^ length of, in
each part, 24 ; independent m morbid pro-
ducts, 228.
Ligaments, softening of inflamed, 260.
Ligature of arteries, effects of, IS2.
Limbs, unequal length of, 67.
Line of demarcation. 300.
Lion's bones, symmetrically diseased, 27.
Lip, arterial tumor on the, 483; cancer of, 595 ;
and see Epithelial Cancer; elandular tu-
mors in the, 475 ; glandular and bony tumor
in the, 445 ; proliferous cysts in the, 362.
Lipoma, 374 : see Fatty Tumor ; arborescens,
376, 622 ; colloides, 376 ; mixtum, 376.
Liquefaction of fibrine, dec, 243.
Liquefactive degeneration, 105; in cartilagi-
nous tumors, 430 ; in cancer, 665 ; in tuber-
cle, 673.
Liston, Mr., on spermatozba in cysts, 350.
Liver, cancer of the, 651.
Lloyd, Mr., on spermatozoa in cysts, 350."
Local disease in cancer, 633.
Lung, cartilaginous tumors in, 422 ; cancer in,
662 ; epithelial cancer of, 585 ; osteoid can-
cer of, 619 ; tubercle in the, 669.
Lymph, for repair, 125 ; in primary adhesion,
135 ; inflammatory, 216 ; its developments,
125; into fibrous or connective tissue, 126:
see Inflammation ; degeneration of, 245,
255 ; varieties of, in blisters, 220 ; supposed
origin of tumors, 329.
Lymphatic glands, chronic inflammation, 245 ;
tubercle in, 678; enlargement before cancer,
504 ; epithelial cancer of, 583 ; medullary
cancer of, 548, 564 ; osteoid cancer of, 615;
scirrhous cancer of, 503.
Lymphatics, in adhesions, 240; in granula-
tions, 150 ; cancer in, 660 ; in cancer, 534.
Lymph- space in bloodvessels, 195.
M.
Macartney, Dr., on immediate union, 131 ;
modellingprocess, 153.
Maclagan, Dr. case of recurring fibroid tumor,
416.
Maintenance, 20; of diseased blood, 46.
Malignant and innocent tumors, fusion of,
668.
Malignant tumors : general characters of, 324 ;
fibrous tumors, 409 ; myeloid tumors, 454.
Mammary gland: contracted and indurated,
witli cysts. 344 ; serous cysts in the, 343.
Mammary glandular tumors, 361, 468; neural-
gic, 396 ; proliferous cysts, 358 ; recurring,'
364.
Many-nucleated corpuscles in myeloid tumora,
449.
694
IKDBX.
Maxillary bones : see Jaws.
Median nerve, consequences of injury of, 42.
Mediastinum, tunfior m, containing teeth, dec.,
373, note.
Medicines incorporated in tissues, 33, 310.
Medullary cancer: varieties, 530; general re-
lations, 530; usual seats, 531; toft kind;
shape, dtc, 531 ; relation and attachments
of lobes, 531 ; capsule. 532; material, 532;
cancer-juice, 532; varieties, 533; bloodves-
sels, 533 ; erectile and pulsating, 533 ; lym-
phatics, 534 ; nerves, 534 ; infill rationg^ 534 ;
m bones, 534 ; with osteoid cancer, 536 ;Jirm
kind, 536 ; microscopi^ characters, 537 ; cells.
537 ; varieties of nuclei, 537 ; of cells, 539 ; of
stroma, or intercellulsr substance, 542 ; affi-
nity with erectile tumors, 544 ; In the letft-
de, 544 ; eye, 545 ; hrea$t, 546 ; tuhcutaneout
ti$iue, 547; multiplicity, 547; absorption,
548; lymphatic glands, 548; rectuwt, 349.
Pathology: influence of sex, 550; age, 5.50;
hereditary disposition, 552; injury, 553; and
disease, 552; temperament. .'>53; multipli-
city and growth, 555; arrest, 554; ulcera-
tion, 555 ; degenerations, 555 ; wasting and
absorption, 555, 558 ; bleeding, 557 ; inflam-
mation, 557; sloaj[hing, 55i8; pain, 560;
cachexia, 560 ; duration of life, 560 ; eflect of
removal, 561 ; recurrence, 562 ; rales for
operations, 563.
Molanoid cancer: general characters, 606;
microscopic, 606; general pathology, 608;
color, 609 ; connexion with moles, 610 ; roul-
tipKcity, 611 ; epithelial cancer, 582.
Meliceris, 342. note.
Membranes, products of inflamed, 224, 226,
233.
Memory, connexion with nutrition, 49.
Menstruation, relation to cancer, 513.
Metamorphosis, in disease, 308.
Mettenheimer, Dr., on the cystic chorion, 356.
Milk : cysts containing, 343.
Mind : eflects of its exercise, 21 ; its influence
on nutrition, 41 ; connexion with a changing
brain, 49; depression of, in relation to cancer,
64«.
Mixed tumors : flbro-cellularand cartilaginous,
384 ; cartilaginous and myeloid. 445; carti-
Isginous and fibro-cystic, 445 ; cartilaginous
and glandular, 440; cartilaginous and can-
cerous, 444.
Modelling process, 153.
Modelling of united bones. 170.
Moles : liability to cancer, 610.
Mollitiesossium, 97 ; its two forms, 99, 267.
Molluscum simplex, 381, note.
Morbid materials in blood, indentity of, 29 :
see Specific Diseases.
Morbid poisons, 306, e. s. : see Specific Dis-
eases.
Morbid structures, maintenance in, 47.
Mortification : distinction from degeneration,
290 ; causes, 291 ; direct, 291 ; relation to
inHammaiion, 291, 294 ; indirect. 292 ; senile
gangrene, 295 : various causes, 29^) ; appear-
ances of dying and dead parts, 297 ; separa-
tion of them, 300; phenomena of necrosis in
bone, 301 ; after loss of blood, 37 ; after
obliteration of vessels, 39 ; after injury oi the
spine, 43.
Motor ncrvrs, influence on nutrition, 44.
Mucous cysts. 34.'); Nabothian, 346; Cow.
perian, 346 ; their various contents, 346.
Mucous membrane, cancer of: see Ephbelal
Cancer ; villous cancer in, 621.
Mucous polypi, 3b'0.
Mucus, 225 ; diagnosis from pas, 253.
Miiller. Prof., on cholesteatoma. 371: on f a-
chondroma, 421 ; on carcinoma reikcu'.arr.
498; on osteoid cancer, 613; on cysto-Mr>
coma, 352, 368, 470, 6lc,
Muliilocular cysts, 35.?.
Muhiple tumors, 327; cartilaginous tomon.
443 ; fatty tumors. 376 ; fibrous tamor»,4ii?;
osseous growths, 465.
Multiplication of cancers : see Cancer, gene ni
pathology.
Muscles, growth of. 57; h3ri>enrophT oi. €1.
e. s. ; eflects of action, 2u ; atrophv and dc*
generation of. 87 ; voluntary. ^7 ; ihr hnr.
90; smooth-fibred. 94; materials dented
from their transformations, 50; hesanc ni
divided, 180; inflamraatioo ol, 267: kvd
cancer in, !t06.
Muscular tissue in fibrous tumors of the uteru*.
399.
Myeloid tumors : relation to the fibroplaitftr.
446 ; aflinity to natural bone -teit are*. 416 :
situations, 446 ; general shape. 447 ; irxrar*.
447; cysts, 448 ; microscopic strucmrr. 44*;
general history, 449; cases. 449: rrcurrmct
and multiplicity, 454; with carttlsge. 443.
N.
Nabothian cysts. 346.
Nsvi, 477, 4f<7 ; pigmentary, liable to caorrr.
610.
Neck, serous cysts in the, 340; blondryrt ra
the. 347 ; proliferous cysis in the, 3<>4 ; mrc*
loid tumor in the, 4.M.
Necrapmia : see Mortification.
Necroais, 301 : and see .Mortification ; or *^nt'
ous growths, 464 ; prt»cedintj csnrrr. ***4
Nerves : adaptation to atrophy. v**7 : hr» -j :
divided, 186; atrophy after division. 1*". i:
granulations. 149; in adhesions. 24(>; ti'-r>:i
tumors in, 403 ; relation of painful tum<.'rt 'o.
394.
Nerve-force, defect of. inducing mortitica* ./»•:.
296; changed in inflammation, 2i^ : d'*'t^rS*
ance of, initiating inflammation. 2>j>
Nervous system : eflfects of sxercise. 2\ , t-
fluencc on nutrition, 40. e. s. ; on secmwr.
43.
Nervous tissues, degeneration of. 100.
Neuralgia, with cancer. 521 ; with taoMKS. 395.
Neuroma. 394. 403.
N euro- pathological theory, 286.
Newport, .Mr., on repair in insects. 114.
Nipple, hard cancer of the. r)(>2.
Noll me tangere, 5s^.
Non-vasculsr part», nutrition of. 39.
Nose, cutaneous outgrowth of, 3^2: epithrlul
cancer on, 574 ; sloughing af:er bleedinj!, 3T
Nosology of cancers, 6t»T.
Nucleated blastema. 129; in blood-clot, 12*2;
ossification of, 164.
Nuclei; cspacity for development, 5^i: tn
parts actively nourished. 51 ; of heart -fiSrc*.
91 ; chiinge uf, in ceils. 127 ; siellaie or
branched, in cartilage. 426.432; erring, as
orij^ins of cysts and tumors, XIS, lUS.
Nutrition: nutritive process, modes of. IT:
conditions of, 26 ; right state ol the bkxsl.
IITDBX.
695
26; assimilation of the blood, 26; life of
blood, 27 ; diseases of blood, 27 ; symmetri-
cnl diseases, 27; seats of election of diseases,
29; identity of specific morbid materials, 30.
Excretory office of each part, 31 ; office of
rudimental organs, 32. Incorporation of
materials of the blood. 33; determining the
formation of certain structures, 34; favoring
the order of development, 34. Complement
tal nutrition, 34; simultaneous changes in
nutrition, 35; commensurate development,
36; constitutional disturbance, 37. Supply
of blood, 37 ; consequences of defect, 37 ;
imbibition by tissues, 39 ; office of bloodves*
sels, 40. Influence of the nervous system,
40; of the mind, 41 ; injuries of nerves, 42;
inconstancy of effects, 43. Healthjr state of
the part to be nourished, 46: assimilation in
diseased parts. 46; and in blood after diseases,
47; its precision. 48; and in the brain, 49:
see also Formative Process.
Nutrition, altered condition of, in inflamma*
tion, 193; contrast of normal and inflamma-
tory, 277.
Nutritive repetition and reproduction, 51.
Nyrophae, outgrowths of, 381.
O.
O'Ferrall, Mr., case of fibro-cellular tumor,
387.
Oily or fatty cysts, 349.
Open wounds, repair of, 1 19.
Orbit, cysts in or near the, 369; fibrO'Cellular
tumor in the, 390; medullary cancer in, 545;
osseous tutnors growing into the, 459.
Organic affinity, 55.
Organic form dependent on composition, 54.
Organization of blood* clot, 120, e. s.
Ormerod, Dr., on fatty hearts, 94; on inflam-
matory products, 285.
Osseous tumors: in soft parts, 456; of bones,
456 ; chief kinds, 457 ; homology, 457 ;
modes of ossification, 457: cancellous, 458;
ivory-like, 458; ofthe skull, 459; sloughing,
461 ; ofthe lower jaw, 461 ; ofthe toes, 461.
Osseous growths of the superior maiillary
and other bones, 462 ; of the skull bones,
465. Multiple osseous growths, 465 ; sym-
metrical and hereditary, 465. Distinctions
of the bone in osseous and other tumors, 466 ;
malignant, 613.
Ossific diathesis, 466.
Ossific inflammation, 236.
Ossification, in repair of fractures, 163; of
cartilaginous tumors, 427, 429; of myeloid
tumors, 447.
Osteoid cancer: general nature, 613; seats,
613; general characters, 614; in lymphatic
elands, 615; microscopic characters, 615;
nbrous, 616 ; osseous, 616 ; affinities to os-
seous tumors, 617; and medullary cancers,
535, 617 ; general pathology, 617 ; secondary
disease, 618; cases, 619; characters of bone
in, 466.
Osteo- chondroma, 421, note.
Osteomalacia, 99.
Osteophyte, 236.
Osteo-sarcoma, 421, note; 466.
Outgrowths: general characters of, 331; cu-
taneous, 381 ; fatty, 374 ; fibrous, 397, 407 ;
osseous, 456 ; multiple osseous, 465 ; of blood-
vessels, 146.
Ova, length of life, 25.
Ovary, cysts in, 352, 353 ; their affinities with
cancer, 366, 626; containing skin and its
products, 368; with teeth, 373; hard cancer
of, 509.
Overgrowth : see Hypertrophy.
Owen, Prof., on ossification, 77.
P.
Pain, in mammary glandular tumors, 471 ; with
cancer, 521 ; nature of, in tumors, 395.
Painful subcutaneous tumors : general seats
and relations, 391 ; microscopic structure,
392 ; pain, 392 ; growth, 393 ; distinctions
from neuromata, 394 ; neuralgic pain, 395;
pain in other tumors, 396.
Palate, absorption of. under pressure, 71.
Pancreatic tumor, 467.
Papills, new formation of, 189; cancerous,
566, 569, 586 ; and see Epithelial Cancer.
Paralysed parts, nutrition in, 43; treatment
of, 88.
Parotid, blood-cysts on or in the, 348; carti-
laginous tumors on or in the, 440 ; cysts over
the* 340; cancer in, 556.
Pedunculated, intracystic, and other growths,
3.57, note.
Perforating ulcers, 293.
Pericardium, absorption of lymph from, 244.
Periodicity in disease, 309, 316.
Periosteum : its injury in fractures, 161 ; can-
cer rising from, 590 ; in medullary cancers,
535.
Peritoneum, colloid cancer of, 626.
Peritonitis, lymph in, 233, e. s.
Perpetuated morbid changes, .48.
Personal modifications of disease, 316.
Phalanx ofthe toe, osseous tumor on the, 461.
Pharynx, fibrous polypi in the, 398.
PhiUips, Mr., on vascular tumors, 489.
Phlebolithes, in venous tumors, 488.
Phymatoid substance, 675.
Phymosis, effect on the bladder, 63 ; preceding
cancer, 594.
Pigment, in melanoid cancer, 606.
Pigmental degeneration of small arteries, 100,
note ; degeneration of lymph, 244, 247, 256 ;
in mucus-cells, 226.
Pigmentary nsevi, liability to cancer, 610.
Places, morbid products in certain, 647.
Plastic force, 53.
Plastic and aplastic lymph, 218.
Pleurisy, lymph in, 231, 232, e. s.
Pleuro- pneumonia, mixed lymi>h in, 223.
Pneumonia, effusion of blcKKi in, 215 ; lymph
in, 223.
Pointing of abscesses, 265.
Poisoned wounds^ 284.
Poisons, morbid, 306, e. s. : see Specific Dis-
eases.
Polypi, 380; fibrous, 397.
Porcellaneous change in bone, 261.
Predecessors, formation after the plan of, 107.
Predisposition, meaning of, 640.
Pressure, effects of, on nutrition, 70; produc-
ing sloughs, 293.
Primary adhesion, 134.
Prodromata of specific diseases, 316.
Progenitors imitated in ofifspring, 54.
696
INDBZ.
Proliferous cysts, 353 ; in the ovaries, 353 ;
with broad-based endogenous cysts, 353 ;
with pedunculated cysts, 355 ; intermediate
forms, 354 ; in the cystic chorion, 356 ; their
minute structure and development. 356. —
With glandular endogenous growths, 358;
in the mammarv gland, 358; method of in-
tracystic growth, 359; consolidation and
protrusion of the growths, 359; general
structure of the growths, 360; their minute
glandular structure, 361 ; their structure not
evidently glandular, 362. — In the lip, 362;
in the labium, 363; in various parts, 363. —
Recurring proliferous cysts in the breast,
364 ; in cancers, 630.
Prostatic-glandular tumor, 323, 476.
Prostate gland, intracystic and detached
growths of, 322.
Purpose, in relation to accidents, 106 ; in dis-
eases, 685.
Pus, 247 : see Inflammation and Suppuration ;
transference in blood. 663.
Pyogenic membrane, 250.
Q.
Quain, Dr., on fatty hearts, 91.
Quekett, Mr , on ossification in cartilaginous
tamors, 427 ; on osseous tumora, 457, 459.
R.
Rabbit's ears, inflamed, 194.
Ranula, probable varieties of, 334.
Recovery from inflammation, process of, 211.
Rectum, hard cancer of, 509; polypus of the,
381.
Recurring cartilaginous tumors, 442; fibroid
tumors, 412, e. s. ; myeloid tumors, 454;
proliferrus cysts, 364.
Recurring fibroid tumors: cases, 412; general
characters, 417; proneness to recur, 417;
relation to malignant tumors, 418.
Redfern. Dr., on repair of cartilage, 174; on
inflammation of cartilage, 267.
Reid, Dr. John, on paralysed muscles, 88.
Relaiing process over an abscess, 265.
Removal of cancer, eflectsof, 667 ; partial, 556.
Repair and reproduction after injuries, lOti. —
Adaptation of parts for future events, 107;
illustrations of the formative force, 107. — Re-
pair of crystals, 108 ; its degrees in animals,
109; at difl*erent ages, 109; according to
amount of development, 110. — Repair in
asteriae and hydrte. Ill ; in tubularia, 112;
l^adual recovery of perfection, 113. — Repair
m insects, 114. and lizards, 115; in man and
other mammalia, 115; general deductions,
116. — Materials for repair, 118; distinction
between subcutaneous and open injuries,
118. — Methods of repair, 120.~ Organization
of blood. 120; its share in repair, 122. —
Lymph, 125; its usual developments, 126;
grnnulaiion-cells, 126; on bones, 128; nu-
cleated blastema, 128 ; developments of
fibrorcllular tissue, 129; from mixed pro-
ducts, 130.
Repair of open wounds, 131 ; by immediate
union, 131. — Vr. Macartney's account. 131;
de<)<Tiption of cases, 132; and experiments,
133 ; the best healing, 133 ; conditions neces-
sary for it, 134 ; &y primary adketion. 131.—
Hunter's account, 134 ; examplr** «ii U- ;r>
cess, 135; its quickness, 136 ; £5 ^ rgjmicf im,
137; glazing of an open wound. IJT; iroc-
lion alter injury, 13S ; granuU:iuR« i'orm:'){.
138; afflux of blood, 139; compar;#on «i'b
inflammation, 140 ; etfusion ot n-(>arar.)e
material, 149; its vasc-ularixatinn. U. :
minute stnicture, 141 ; without »u|;ipiiri'..>n.
141 ; development, 141 ; arrt* «t i>r error. HI,
156; and diseases, 142; contraction. 1>;
chemical changes, 143; formation ot new
vessels, 144 ; three modes. 143. — ;hat 1>jm.i!-
growth, 145; by channelling, 14T: eir.ml
arrangement of vessels, 148; struciurr. Ih.
relations to organization, 149; d««rKipoKDt
of nerves and lymphatics. 14'*. IV>; ^x $f
etmdarif adhe$ion^ 150; its plan. 150; 1 la-a-
pies, i51 : conditions ncceMsry. IM . \ff
sco&6ifi^, 151 ; its process with bliMi. l^J;
with pus, 152; supparatioo and scars ,ire
these words].
Repair of fractures. 160; nature and e 1*1 3t
of injury. 161 ; extravasation, 161 ; :adA9*
mat ion, 161; period of calm. Iii2; com-
mencement of repair, 162; immediate uajM,
162; reparative material or callus. l«'<'i; ;i
rudimental stste. 163 ; ossification thr u;)
fibrous tissue, 163; through ("ir.il^ircr. I'-t.
characters of the new bone. !»»'»; ^-^^r.^- kM
the reparative material, 16.'>; pri^v^:*-:! k<
ensheathing callus, 167; inienor r4!lu«. I'C;
intermediate callus, 167; ditffrencrs i>t re-
pair in man and animals. 169; mAit.ic
after the repair, 170; repair of com:hLi.j:i
fractures, 172; times of the stagc-i» oi :*.- r«-
pair, 172; failure of repair, 172; falw j^«.r.:«.
dtc, 173.
Repair of cartilage, 174; of tendons. ITS.
disadvantages of open wounds. 17«; <:r
of dividing the cellular sheath. 177: n , u
after subcutaneous division, 177; n-trii ••.1
of upper iwnioii, 177; exiravawuKi ;'T.
exudation, 177; reparative niattri.. IT";
its development, 178; imp«Tiisc:.i'n. IT*;
strength of the union, 179. Of ni:iH..r«.
180. Of arteries and veins, 1*^1; wih -.::■. li
wounds, 181; with partial di%i».o::. i*i.
with complete division, 181 ; cou:rjcr.«<' :.':>
retraction, 181; after ligature, ]'*,<; i-'r*.*;)-
mation of the tied end. 183 ; contrar:i n 1
the part above it, 183 ; changes in tbv « ^;-
nant blood, 184. Of nerves. l»rf'»; c3-?> :
pritnary union, 186; secondary union. >•;
formation of new fibres, 1>V!> ; repair «.>t u r^ir-
centres. 188. Of skin. 1^9; new torn i'..c
of papilloB and cuticle, 169 ; relation to iuC lO-
mation, 190.
Repetition, nutritive, 51.
Reproduction, nutritive, 51 ; after in.ur.««:
see Repair.
Reptiles, repair in, 115.
Resolution of inflammation, 244.
Reticulum of cancer. 664.
Rheumatism, localization of, 284.
Rickets. 99 ; efl'ect of. on tibia*. 6^.
Right state of blood, 26.
Ringing, effecs of, 33.
Robin, M., on vessels in erectile tumors. 4-^!.
Rodent ulcer. C>>^H.
Rokitansky, Prof., on the formation ot rj*:*.
334>; on degeneration of arteries. 1m>'; on
endogenous cells in cancer, 5^*1 ; ou inilam-
INDEX.
69T
matory products, 219; on stroma of cancer,
&c., 542 ; on tubercle, 669, Slc.
Rudimental organs, purpose of, 32.
S.
Sanguineous cysts, 347 ; their various contents,
347; in the neck, 347; in the parotid gland,
343 ; internally fasciculated, 348 ; formed from
dilated veins, 348.
Sap, cflects of accumulation, 40.
Saponification of cancer, 557.
Sarcoma, albuminous, 416; gelatinous, 379,
440, note ; scro-cystic, 352, note ; 358.
Scabbing, healing by, 151 ; and see under Re-
pair.
Scars, maintenance and growth of, 47 ; their
contraction, 158; improvement and gradual
perfection, 159; loosening, 159; warty and
cancerous growths on, 589.
Schroeder van der Kolk, Prof., on lymphatics
in adhesions, 239 ; in cancers, 534 ; on tu-
bercle, 671.
Scirrhous cancer, 490 ; usual form in the breast,
490; usual state of the gland. 491 ; hardness,
491 ; size and shape, 491 ; adhesion and re-
traction of tissues, 492 ; cut surface, 493 ;
mixture of cancerous and natural structures,
494 ; wasting of natural tissues, 494 ; cancer
juice and stroma, 495 ; infiltration of cancer-
structures, 495; cells, &c., 496; degenerate
structures, 497 ; degenerate normal struc-
tures, 498; reticulum, 498; fibrous tissue,
500. Varieties : acute and chronic, 501 ; of
the nipple and skin, 502. In the lymphatic
glands, 503 ; in the skin, 505 ; muscles^ 506 :
bones, .507; intestinal canal, 508; mingled
forms, 509; fibrous cancer, 510; in ovaries,
&.C., 511. Pathology: influence of sex,
512; ase, 5.12; of nnenstruaiion, 513; here-
ditary disposition, 514 ; injury, 514 ; general
health. 515; first appearance, 515 ; growth,
516 ; multiple growths, 516; ulceration, 517;
superficial, 517; substantial, 518; softening,
518; arrest and healing, 519; in connexion
with, phthisis, 519; shrivelling, 520; pain,
521 ; cachexia, 522 ; primary and secondary,
523 ; multiplication, 523 ; duration, 524 ;
effect of age, 524 ; effect of removal, 525 ;
recurrence, 525 ; second recurrence, 526 ;
rules concerning operations, 528.
Scrofula, relation to tuberculous diseases, 677.
Scrofulous matter, 243, 245, 676.
Scrotum, cancer of; see Epithelial Cancer;
fattv tumor in the, 377 ; fibro-cellular tumors
in the, 385 ; hypertrophy of, 381.
Sebaceous and epidermal cysts, 370 ; heredi-
tary origin, 370; two-fold formation, 370;
various characters, 370 ; of the walls and of
the contents, 370; ulceration, 371; fatal
case, 372; protruded contents becoming
vascular, 372 ; connected with epithelial
cancer, 575.
Secondary adhesion, 137, 150.
cysts, 353, 355.
Secretion, influence of nervous force. on, 43.
Semi-malignant tumors, 419, 455.
Seminal cysts, 350; their spermatozoa, 350;
connexions, 350; diversity of contents, 351 ;
degeneracy, 351 ; spermatozoa in the sac of
the tunica vaginalis, 351.
Senile gangrene, 295.
Sequelae of diseases, 316.
Sero- cystic sarcoma, 352, note ; 358.
Serous cysts : their contents, 339 ; seats, 339 :
in the neck, 340 ; connected with the thyroia
gland, 341 ; transformations of vascular tu*
niors,341 ; with vivcid contents and cholestea-
rine, 342 ; near the gums, 342 ; in the mam-
mary gland, 343; dilated ducts, 343; auto-
genous cysts, 342 ; confusion with mammary
cancer, 344 ; large single ojsXs, 344.
Serpent- venom, 312.
Sex, influence of, in cancers: see Cancer,
general pathology.
Sexual characters, related development of, 35.
Shifting of tumors, 377, 415.
Shortening of bones, 69.
Simon, Mr., his observations on cysts, 336 ; on
extension of cancer, 660 ; on morbid poisons,
310, e. s. ; on scrofula, 677.
Simultaneous changes in nutrition, 35.
Skeleton of cancers, 542.
Skin, cancer of: see also Epithelial Cancer;
hard cancer of the, 503, 505 ; intracystic for*
mation of, 368 ; outgrowths of, 381 ; repair
of wounds of, 189; reflected, union of, 133;
tubercle in, 680.
Skull, hypertrophy of, 64, e. s. ; atrophy in old
age, 96; cartilaginous tumors of the, 436;
granulations on the, 139, 150; myeloid tu-
mor of the, 451 ; osseous growths on the,
464 ; osseous tumors on or in, 459.
Slough : see Mortification.
Smitn, Mr., on neuroma, 395.
Soft cancer : see Medullary Cancer.
Softening, in inflammation, 258 ; over an ab*
scess, 265 ; of cartilaginous tumors, 430 ; of
fibrous tumors, 403 ; of cancers, 665; ofta*
bercle, 673.
Solution of ulcerating parts, 272.
Soot -wart, 595.
Spallanzani, on reproduction of parts, 106.
Specific diseases : distinctions from common
diseases. 303 ; specific characters, 304 ; plan,
or construction, 305; causes, 306; local and
general phenomena, 306; disproportionate
cause and effect, 307 ; disproportionate local
and constitutional states, 307 ; symmetry,
&c., 308 ; selfau^mentation, 308; transfor-
mation. 308; periodicity, 309 : theory, 309:
its application, 311; introduction of morbid
materials, 311 ; their effect on tissues, 311 ;
example of insect-bite, 312 ; local aptneas
for disease, 314 ; effect and changes in blood,
314; increase, 314; transformation, 315;
combination, 316 ; separation, 317 ; charac-
teristic formation of new bone in, 237 ; mor-
bid materials, incorporation of, 283.
Sphacelus : see Mortification.
Spine, cartilaginous tumor on the, 429, 436.
Spinal cord, atrophy of. 104 ; effects of ii^jory
of, 45 ; repair of injuries of, 188.
Spleen-like tumors, 447, note.
Spurs, effect of transplantation, 60.
Stagnation of blood, 199, 203.
Stanley, Mr., on pulsating tumors, 533; on
scrofulous disease in bone, 682 ; on necroais,
302; on removal of exostoses, 457.
Steatoran, 374, 376 : see Fatty Tumor.
Stilling, Dr., on repair of bloodvessels, 181.
Strangulated parts, slouching. 293. 21)9.
Stricture, cancerous, of mtcstine, 509.
Stroma of cancer, 495, 501, 533, 542, 624,656:
see Scirrhus, &c.
698
INDEX.
Structure, dependent on compoeition, 54.
Struma, relation to tuberculous disease, 680.
Subcutaneous injuries, repair of, 118.
ncBvi, 479, 487.
tissue, cysts in the, 369 ; medul-
lary cancer of, 547 ; fibrous
tumors in the. 403; painful tu-
mors in the, 391.
Sab-maxilliary gland, cartilaginous tumors on
the, 440.
8ub>mucous tissue, fibrous tumors in the. 403.
Suppuration : in repair, 153; characters of pus,
154; pus-cells, 154; liquor puris. 155; na-
ture of pus, 155 ; relation of the cells to those
of granulations, 156 ; their imperfection or
degeneracy, 156 : the same of the liquor
puris, 157; which may be a liquefied blas-
tema, 157; use of pus, 158. — Inflammatory,
218, 247; and see Inflammation; of cancer-
ous glands, 549, 584.
Syroe, Mr., on transition -tumors, 414, 418.
Symmetrical diseases, 27 ; osseous tumors, 465.
Sympathetic nervous system, influence on
nutrition, 45.
Synovial cysts, 345.
Syphilitic ulcers, &c., 305, 308, 314, &c.
T.
Teeth, life of, 23 ; absorption and ejection of
fan^s, 50; induration of, 262; overgrowth
of, m rodents, 71 ; repetition and reproduc-
tion of, 51 ; separation of, in old age, 302 ;
in cysts and tumors, 373.
Teeth-pulps, effects of inflammation on, 269.
Telangeiectasis, 478.
Tendons, healing of divided, 175 ; cartilagi-
nous tumors near, 435.
Testicle, inflamed after stimulus of the ure-
thra, 209; cartilaginous and cancerous tu-
mors in the, 444 ; cartilaginous and flbro-
cystic tumor in the, 445; fibro-cellular tu-
mor in the, 390; flbro-cystic tumor in the,
401 ; hydotid, 401 ; medullary cancer of,
534, 544, 554 ; osteoid cancer of, 613 ; tu-
bercle in the, 676.
Thickening, by inflammation, 234 ; of skull, 65.
Thrombus, 184.
Thyroid gland, introcysiic and detached
growths of, 322; tumors, 476; cysts in or
near the. 341.
Tibia, lengthening of, 67; cartilaginous tumor
on the, 432; myeloid tumor m the, 448;
great osseous tumor of the, 458.
Time, an element in disease, 309.
Tissues, influence of, in inflammation, 221.
Tissue-germs, in nutrition, 52.
Toe, osseous tumors on the great, 461.
Tongue, epithelial cancer on the, 574; fatty
tumors in or near the, 377; flbro-cellular
tumor in the, 390.
Transformation, in disease, 308; of diseases in
hereditary transmission, 640 ; of natural
struciurcs into cancerous, 651.
Transition tumors, 418.
Traumatic gangrene, 298.
Travcrs, Air., on healing in the frog's web,
138; on inflammation, 192.
Trenibley, experiments on hydrae. 111.
Treviranus, on the excretion oflfice of each
part. 31
Trigeminal nerve, influence on nutrition, 42,
44.
Tuberculous disease, incompatible with ctn-
cer, 519, 637.
Tubercle, 669 ; type in the lungs, 669 ; gray
and yellow forms. 669; minute etmctore,
670; origin in epithelial cells, 671; abor-
tiveness. 672 ; degeneration, 673; softening,
673; discharge by ulceration, 674 ; cavities
and ulcers, 674 ; tuberculoid substances. 675 ;
scrofula, 676. — In Ijrmphatic glands. 678 ; in
integuments, 680 ; in bones, 681. — Likeness
to inflammation and to cancer. 683.
Tubercle, cancerous, on the face, 588.
Tumors: seethe specific names. — e.f;,Seromi
cyst. Fatty tumor, &c. ; contrasted with
hypertrophies, 318; with products of inflam-
mation, 319 ; their property of growing. 321 ;
nutrition irrespective of the rest of the body,
322 ; as parts overgrowing, 321 ; cessatioo
of growth, 322. Malignant^ general charac-
ters of, 324 ; proportions assigned to injury,
329; supposed origins of. 329 ; classificatioii
of, 318, 324, 330, glc. ; division and nomen-
clature, 330 ; classiflcation of. objections to,
332 ; distinguished from inflammatory pro-
ducts, 280.
Tunica vaginalis, containing seminal fluid, 352.
Turck, Dr., on atrophy of the columns ojf the
spinal cord, 104.
U.
Ulcer, cancerous, 518, 576 ; cancroid, 588 ; per-
forating, 293 ; of stomach, 589 ; rodent, 588 ;
specific, 305, &.C. ; becoming seats of can-
cer, 594.
Ulceration, 270; and see Inflammation; in
sloughing, 301 ; liability of certain tumors
to, 325; of cancer, 516; and see Cancer,
general pathology ; contrast of cancerous
with simple, 326 ; tuberculous. 674.
Ulna, increapod after injury of radius. 69.
Union, immediate, or by the lirsi intention,
120; by adhesion, 134 ; of granulations, 150.
Urethra, vascular growths in the, 4^6.
Urinarjy bladder, hypertrophy of. 61 , 6^1 ; poly-
pus in the, 381 ; villous cancer in, 6Ci). e. s.
Uterine growth ond tumor, contrasted. 319.
Uterus, development in pregnancy. 57 ; fattv
degeneration after parturition, 95 ; growth of,
round tumors. 319; tumors imitating the
structure of, 319; epithelial, cauliflower-can-
cer of, 586; fleshy tubercle of, 397; tibroos
tumors in, 400, 403; flbrous polypi of, 397;
cysts in flbrous tumors in the, 401.
V.
Vaccinotion, efTects of, 284.
Vaccine virus, effects on blood, 47.
Vagina, flbro-cellular tumors by the, 387; epi-
thelial cancer of, .'S86.
Vascular and non-vascular parts. 39.
Vascular tumors: synonyms, 478; likeness to
erectile tissue, 478; chief kinds. 479; capil-
lary, 480; arterial, 482; venous. 484; gene-
ral characters. 485: enlarging blood -spaccfs,
485 ; tissues affected. 486 ; general characters
of subcutaneous naevi, 487; cysts in. 4!*8,
341 ; relation to cancers, 489.
Veins, healing of injured, 181 ; dilated into
cysts, 348 ; cancer m, 667, 622.
IBTDEZ.
699
Venom of insects, &c., 312.
Venous vascular tumors, 484.
Vertebne, cartilaginous tumors on the, 429,
436; tuberculous disease in, 681.
Villous cancer : general characters, 620 ; den-
dritic growth, 621 ; bloodvessels, 623 ; struc-
ture, 623.
Virchow, Prof.,on cauliflower excrescence, 587;
on fatty degeneration, 81 ; on inflammation
of muscles. 267; of the cornea, 268 ; on rare-
faction of bones, 507 ; or« tubercle, 671, 678 ;
on vessels in erectile tumorsi 481.
Virus, eflects of, 284.
W.
Waller, Dr.. on formation of new nerve- fibres,
188 ; on eflects of division of nerves, 103.
Walsbc, Dr., on cancer, 490, 529,642, &.C. ; on
rarefaction of bones, 507.
Wardrop, Mr., case of healing by scabbing,
152; on medullary cancer, 545, 612, &q.
Warren, Dr., on lepoide8,594 ; on colloid can-
cer, 628.
Warts, becoming seats of cancer, 594.
Warty growths, 569, 587 ; on scars, 589.
cancer ; see Bpithelial Cancer.
Wearing out of ports. 20.
Williams, Dr. C. J. B., on varieties of lymph,
128.
Dr. Robert, on morbid poisons, 310,
e. s.
Wood, Mr. Wm., on painful subcutaneous
tubercle, 391.
Wormian bones, in hydrocephalic skulls, 64.
Wounds, repair of, 118. e. s. : see Repair.
Wrist, osseous tumor on the, 456.
X.
Xanthose, 447.
Z.
Zoology, comparison of nosology with, 668.
Zwicky, Dr., on organization of blood, 120,
184.
THE END.
THE PHILOSOPHY OF LIVINO.
rOBXERLT SENIOR 8UBGB0H OW MIDDLSBXX BOSPITili, PB0FXS80R OW AHATOKT, XTa
** For though we Christians do continuallj aspire and pant after the Land of Pro«
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ARTHUR'S MANUAL OF DISEASES OF THE TEETH,
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hai |irrfittiiii-d tun duties in a very creditable ityle, and ie enli"^ to the thank* nf ihi**^ « ri • J<i ti : r< • .
havini eiiaMvd Caxi'.-iux to addreM hiinaelf alin<«l aa wrli to Aaierma rvaiirm. a« tlKiuch the w- .r'^* :■».'.-«- ■ ■ ■ •
m the KiisliAh lauKuare Wa have met with but few tranalaiioua that couvv)cd llie »;>in: uf ;>ir ••::..:.... ^ , . •
c Jcoplele aurcvw. — Wrrtrm Jmemal 0/ MedtctM and Sur^fery.
" It* adoptiiin by the Riiyal C<iuncil of Public Tnitnictioii — the piMutinn ami chnrartrr nf it< ^<^^ r i« ■ u •'•»r ei
oheteirira — hi!i oji|Mirtuniiiea fi*r clintral exnenenoe, and the fact of the earlr lUrnaml in F'ri'.'^ i-<- . •»•■■ ■ r »«.
piteaeiit mnm: fxirm<iir. rMtmiineiHlatiima of the work, which are fully «u*!a]nMl l>v f% iiiiriii«ii- ti.>-r '«
"Written ex|»reM!y fur 'the um« of atudeiiis of nirdirine. niul thtMr of niidwiferv c*:*^-] i!;!-.* i'« t, ; ■ -, -. ,
and ev[>lirii. (ireM'nt'iii!; 'anHMlenwHl aniiimary of the Iradint principle* e«;B'iliOini hvu.'' nni**-^ . - ■ r
art.' aiid »iifh rlrnr, pnirtiral dircrtiiiiiH fiir the maniirriufni nf th«* fiii*::ii:iiit. |uritir:fni. aii-! ..•'•■ >* •
been anni-tniiKtl bi ihenHMi authurituiive pnictitiiinf!ni. nml rnnr.riiiM] l<v ihr uiit*:<r'» timi vi • ■ •■ »
hit iiiittcnals rpini the wriiinsa of the entire boJv of an'.rcrdi'nt wiiIit*. r.imiillv ii-«'i:u' f.'-ir 1 .. - ■■ ■ ■ •• - 1 . ^
bv hii <mii iIhiIv rxpenriire, and n>icctiiie all kiii-h an were fMlikii'inl hy the ii<iti)r->->i< r i«* «'■■■• :^..- ■.. •
nmliate n>iMTv;iriiiu. hn hoa funned out of thrin a IhmIt of durinni*. aiwl a a}**!*!!! i>i' ;-r:i- :•■- 1. r • ■ 1. <• - v
trnli't niul rtiiiinvM ni the i*lenn-«t and nuM Mniplr nmnnrr i^rMkiiilt-
"111 thf I'trm'inrs^ of all thi> nmre itii|Nirt:iiit of \\n U'Tirhmi", w# fiil!v ni*j'i:i'»i'i", r,-, I ri-, *t»i - ■ % . ■ • •
rr'*oiiitiifi:.J iI:h umk to thi> iiiiilical htuih'ii', an uiic that h:U | r<>vi' to hiiii a h-ilv niul \ •.: i' !■■:;- i, ' i • • ■ «
of «ili»trlrn.> " — 3/'-.'ii at Krunnnrr.
*''rhi<* Work, niiirt* ininriilarly intenditl for the use «if utihlcnt* i»f inrilinne. i« an ii'im -i 11 . ' • .-
tun-^di-liviii- 1 rn- ^l i':i/i-iiit. l!i I'-ariR. for M-ver»l yearn pa«.l l! n iil-.Tii- wi^i^ :%•} .; •• ; r . ■ .. ■
Pulil'f liiitiiiiMxii. Ill III \uv r«>^|i«>i*t«, in itH ceniT.il arRiii.«'nii-n!, it ii-«i-iiilii>- n,><»! --i ■:.- ••■ 1 1 -.
the hiiiir ••!• Hi'. Ill Krjiii"!-. yit iii the ni-i-n it a;i;ir:ini tudiiliT cH^ru;!!! v T:.'- iT.. -r i. :• ■ i
tJK' tirWH III i'iiii'i>«%.ir<t N.it*.'i'li', Valty. ami P. Iiiihiii<i, nthirn .'iri> iii>: lniii.i! cli- ir.i • > ■ • toil n
wiirkt ' \V;i, f. iMWrvr'. r.i- h-ii |iiit ilif viiwii of thi-«e ti-irln -s 'i!i.|i-r !ii ai v •■■■•i'- «. i' .
has ilrawii i \ :,iii| imln i*:i' ii-mu nI1 i|,i> mnrr ininlt'ni wri't-pi «liii !..iVf j i :■.••■. ':.•■ ' ■
o{i|iiiMn iif M ' .r*'!-. n-i iilt I 'lit rf l.i'«H til iiv.il.ii'v, ha^ Ix«hii r-ii»»'i:»i-.| In '. ,- > ".i *.■■«.». . . i- ■ .
turv III llii> r,-i:4ir:-« Hi it (uLi* |i!.ir«> m I hi* ••\.iry anil •ivmiiiri. I • :' <u :i'.)-.l .I'.'i r ■mik r *. :, ■ ii • ■ « •
|ie«-n |iri'M-;i'i .1. ui <>r<l<-r l>i rimn- rlcarlr illnkTale aiwI Miii.-ility tin- tr\r, :i.:i',. 'i-t i-it n ,t: '.:.•■ ^ ■ i
dur'rnii. Mli:<-!. is n»'A firidiic «•• nnii'li n'lriilinn thrtji iii ii.ii r-<iiirrk :i:i.l in I- -in .-r u .■! ' # '. : '. -.
every rf lili-r ' 'lUf Xinerifaii tran^iatur has rYiTuleij hi« tas* m a *rn •a[i'>ii<-:i-r\ ii.;i!ir,i r . -.:• • : -.
nn iiiili.^hi :o. ni>- <!• le-tiiiK nf the e^iin-ial thiiiikn of ti.e itiii*-r:i'.iu n-.iilrr. i->r :.»>% -a i::ii> Ui.d.:. n
lariri! »'«irk nf iri .iii^ei on luulwifiTy. — AVw IV* Jtmrmil «/ Midinnf.Uir Mmrk, '.-.'•
"In l-Nll.ti ir:i w i« ihe rf;iiltatiiin nf the flmt nli'rtui m Kr.im-*'. ihi" il »i» nl-i;'!-.! I ; '!■•• V-f. •' <' ■
InVriii";>>ri N ■ i->i.iiise ul l:iin-«, or inrreakc nrftmiiiar f!!.irt« Mv .i:!iri», li i> rli:iii."»il •.:i- ki ii- . i -■ ■
In I'S h:;;-i ri:i-.'H
'• llrii'."i'. I'f- :i t I iiii> lutnt (leniiil. wh.iti-vi-r is new, un-ful or vi£jt»ii\r. h.u U-*n .'t.'iiiN ... .ti -.
Ittl — li'^fl'ifi MnUful ami HyrykOi Jvurnal.
" Whi«n an H-i'Jmr win) mar In* a ktranrer pn-vn's him».i''f If f^iT ihr (iri:i-«»-i'i m *i.r ^*'l*•i^'^■ ■ y •■ ■■ 1
prn;ii r r»»i iil !■•: nur rfaili-m riijuins ua tn infiiim lln'in ■•iiiielhirie of t'lr r;i:ir:K-4 r iIl-I •'...■h: :..- i ■ -
I'a/.fi'n. r.'.f a-i';,iU ot tli^ ah-iii> irt'aiiM-. wi». f-ir a nninlMT i>f ifar", |-!ii«.i-..i;:- ■■ ■■■<: ■■ • n- : ■ ■ -
|vii»e III 'i"*- '..-% » "f r.ttiv wli»rF In' •■i.,M^i-i| thr ani;>li«t ii|i|Kiiliiiii'ir<» f.»r am. • it.i.i .. .« •!!•■ 1 -i ..
fill Ml IfV ii!i(»:r'' .-a I i*rr.i«p«. .iiiil »*:iri« a'l lll»■^■ ii;ifrittiit|ii|i wan iii ulc t.i tm » .. : ■ r .1 *. »• • ■ -
ra|a:i:iM-!.; \I..i.sr<ir «' w;i* htoiiii*. a l.m:; timr ihrt de cUut-jur tn rr>i!r«».ir I-.i'-i-. in-; .. • . . -
(rnio^ietl V.kim 1 |ii'<iiili-<i. ii** h:i<t Urn a lecturer, inr Ihi' laiJ eii:lii oi ten leir*. -■ii «.. irt.;t fi. it. ■. ■ •■ ■ . •
in (III- 1- i:-i--i*v .-r ■-•<!i'iii<'C jirii*'* *%-ir Wi* think wr have Mid rnniiKh l-» ki'.i»:v ii.i- ri :.iii r i.ij' ■ .. . . > ■
OMai'k. » 'i! :i *-'i.|iir iiDiJ II ■.ruijial ph%«iriiin
'■V,.- .iM* t : ■•^«iii.' u:iii>ir .iirii-ir irriintiiii. we mav lie iM>rm."iil to ataU th:it I..* u.irit i« m . ■ ■ .- •
rt'.^- ••: tiif ii .1. .,1, I'.i. •,1,). ,,-t i.f ,,!,.>;ri,>. : ui„| t:ikiiii;llie iHHiii II* :i wli-'V. :' HI.- n ■' .ii:!. - .
aiii .■! -I » !iii. II * i-'. mi I ill- k.iiiir «ii'>jrct 'I he plali-a are well exi-rutrd. auU »i.; a**,*! the ir.i t .■ 1. i # , j.-
dfr«;aii'!i«i'.' !:.i" '•i'
•■ M I a/iTi- \\ ^ I IK ii Kln'i'r.f.ii «rienr<' ntitoihepreient dav.ami the reader ««i:; iiiiil th» m . ■.'-■ •». .red
of ni«» m: in v i|,«"i| | jn, j 1 .m |iiiiy exaiiinir<l
" ^^'' '■•I'll-*' !!i.iij r..:iii: • iiii hi« l""»k tn the narrfill Iirru«al W the atndriit ailil \-':\-U\f*.rr , a«*-- ^ >C1
that iiiF« will In* aiiii.li ii-H4iiliil t'.ir a artful Mudy of thi- work." Sm OT:mu M*U. qiU >mr^ A^rvu.. Jhfae itOL
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